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IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK MANUAL2018
VERSION ONE
Draft (next version end Oct)
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IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK MANUAL2018 VERSION ONE
iv
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The National Department of Health conceptualised the Ideal Clinic Realisation and Maintenance
(ICRM) programme in 2013. Operation Phakisa was launched in November 2014 to rapidly scale
up the Ideal Clinic Model across all PHC facilities. In 2015 the ICRM programme was officially
launched. The main intention of the ICRM programme was to enhance the Primary Healthcare
system towards achieving the goals of universal health access to a high quality of care.
The ICRM has resulted in the following benefits to the health system:
• Improved oversight on the status of clinics
• Data immediately available on equipment and infrastructure status of all clinics-thus able
to quantify needs and related costs
• Serves to motivate staff at clinics and district officials to improve facility status and
service delivery
The successful implementation of the ICRM programme created the impetus to extend the goals
of universal health access, cost effective and efficient services of a high quality and standard by
creating a similar framework for Ideal hospitals as the Ideal Clinic framework.
The development of the Ideal Hospital Realisation and Maintenance Framework (IHRM-F) is a
critical strategy and intervention to facilitate improved health service delivery and strengthen
health system effectiveness by capacitating hospitals to identify and address key issue. The
IHRM-F will serve as a benchmark mechanism to monitor Health System Strengthening activities,
to improve efficiency gains in service provision and to improve patient experiences.
Ms Jeanette Hunter, Deputy Director-General, Primary Health Care in the National Department
of Health led its completion. I am pleased to acknowledge the work undertaken by a technical
working group consisting of: Mr Ramphelane Morewane, Mr Bennet Asia, Dr Shaidah Asmall,
Ronel Steinhöbel; Dr Ozayr Mahomed and Dr Saajida Mahomed.
The development and publication of this document has been made possible with the support
of the United States Agency for International Development (USAID) under the United States
President’s Emergency plan for AIDS Relief (PEPFAR) through Right to Care.
Design & layout: www.itldesign.co.za
IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS ...............................................................................................................................II
SECTION 1
INTRODUCTION ............................................................................................................................................4
SECTION 2
BACKGROUND: INTEGRATED HEALTH SERVICE DELIVERY PLATFORM .............................................7
SECTION 3
IDEAL HOSPITAL ......................................................................................................................................... 12
SECTION 4
PURPOSE OF THE MANUAL ...................................................................................................................... 14
SECTION 5
ABOUT THE MANUAL ................................................................................................................................ 15
SECTION 6
ASSESSMENT METHODOLOGY ................................................................................................................. 16
SECTION 7
IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS ........................................... 20
SECTION 8
ASSESSMENT OF IDEAL CLINIC ELEMENTS .......................................................................................... 34
REFERENCES ............................................................................................................................................ 256
SECTION 1 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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LIST OF FIGURESFigure 1: Integrated healthcare service delivery platform ......................................................................7
Figure 2: District Health System- ...............................................................................................................8
Figure 3: Services across different levels within Health Service Delivery Platform .......................... 10
Figure 4: Components of the Hospital Package of Services ................................................................. 11
Figure 5: IHRM-F Components and Sub components ........................................................................... 13
SECTION 1 INTRODUCTION
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LIST OF ABBREVIATIONSANC Antenatal Care
ART Antiretroviral treatment
CCMDD Central Chronic Medicine Dispensing and Distribution
CHW Community Health Worker
DCST District Clinical Specialist Team
DHIS District Health Information System
DHMT District Health Management Team
DHS District Health System
DoH Department of Health
DPSA Department of Public Service and Administration
DSP District support partner
EML Essential Medicine List
EMS Emergency Medical Services
HIV Human Immunodeficiency Virus
HRH Human Resource for Health
HTS HIV testing service
ICSM Integrated Clinical Services Management
ICRM: Ideal Clinic Realisation and Maintenance
IHRM-F: Ideal Hospital Framework
IPC Infection Prevention and Control
MCWH Maternal Child Women’s Health
MOU Maternal Obstetric Unit
NCD Non-communicable diseases
NDP National Development Plan
NGO Non-Governmental Organisation
NMC Notifiable Medical Conditions
NHLS National Health Laboratory Services
OHSC Office of Health Standards Compliance
PDoH Provincial Department of Health PEC
PEC Patient Experience of Care
PHC Primary Health Care
PMDS Performance Management and Development System
PPE Personal protective equipment
PSI Patient Safety Incident
SANC South African Nursing Council
SLA Service Level Agreement
SOP Standard Operating Procedure TB
TB Tuberculosis
WBPHCOT Ward Based Primary Health Care Outreach Team
WISN Workload Indicator Staffing Needs
UHC Universal Health Coverage
IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTiON
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INTRODUCTIONThe Ideal Hospital Realisation and Maintenance Framework (IHRM-F) is a critical
strategy and intervention to facilitate improved health service delivery and
strengthen health system effectiveness by capacitating hospitals to identify and
address challenges. The IHRM-F will serve as a benchmark mechanism to monitor
Health System Strengthening activities, to improve efficiency gains in service
provision and to improve patient experiences.
THE DEPARTMENT’S FIVE YEAR STRATEGIC GOALS ARE TO:
• Prevent disease and reduce its burden, and promote health
• Make progress towards universal health coverage through the development of the National Health Insurance scheme and improve the readiness of health facilities for its implementation
• Re-engineer primary healthcare by: increasing the number of ward based outreach teams, contracting general practitioners, and district specialist teams; and expading school health services
• Improve health facility planning by implementing norms and standards
• Improve financial management by improving capacity, contract management, revenue collection and supply chain management forms
• Develop an efficient health management information system for improved decision making
• Improve the quality of care by setting and monitoring national norms and standards, improving systems for user feedback, increasing safety in health care, and by improving clinical governance
• Improve human resources for health by ensuring appropriate appointmnets, adequate training and accountability measures.
The National Health Insurance (NHI) is intended to move South Africa towards Universal Health Coverage
(UHC) by ensuring that the population has access to quality health services and that it does not result in
financial hardships for individuals and their families. The implementation is underpinned by the National
Development Plan (NDP)1 which envisions that by 2030, everyone must have access to an equal standard of
care, regardless of their income, and that a common Fund should enable equitable access to health.
• In order to meet the objectives of the NDP; the National Department of Health (NDoH) strategic
objectives 2014-2019 amongst others has a focus on improving
• readiness of health facilities for the National Health Insurance scheme,
• health facility planning by implementing norms and standards;
the quality of care by setting and monitoring national norms and standards, improving system for user
feedback, increasing safety in health care, and by improving clinical governance.
1 South African National Department of Health. National Health Act, 2003 (Act No, 61 of 2003)
SECTION 1 INTRODUCTION
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DEFINITIONS, PURPOSE AND APPLICATIONS:1. Definitions2. Scope and application3. Purpose of regulations
USER RIGHTS:4. User information
5. Access to care
CLINICAL GOVERNANCE AND CLINICAL CARE:6. User health records and
management
7. Clinical management
8. Infection prevention and control programmes
9. Waste Management
CLINICAL SUPPORT SERVICES:10. Judge and value11. Assess major decisions12. Provide info for planning
FACILITIES AND INFRASTRUCTURE:13. Management of buildings
and grounds14. Engineering services15. Transport management16. Security services
GOVERNANCE AND HUMAN RESOURCES:17. Governance18. Human resources
management19. Occupational health and
safety
GENERAL PROVISIONS:20. Adverse events
21. Waiting time
22. Short title and commencement
On 2 February 2018, the National Minister published Regulation 672: Norms and Standards Regulations
Applicable to Different Categories of Health Establishments to promote and protect the health and safety of
users and healthcare personnel.
These regulations contain 22 sub-regulations across the following domains: User Rights, Clinical Governance
and Clinical Care, Clinical Support Services, Facilities and Infrastructure, Governance and Human Resources
and General Provisions.
A number of health system challenges have a direct impact on the hospital environment that impact on
overall health outcomes. These challenges include amongst other: Funding constraints; inadequate human
resource distribution and allocation; ageing infrastructure; inadequate revenue collection; inefficient supply
chain management3. In additions the findings from the National Health Facilities Audit 2012 indicated that
only 47% of hospitals were compliant to positive and caring attitudes measures; 52% to of hospitals were
compliant improve patient safety and security; 62% of hospitals were compliant to cleanliness; 64% to of
hospitals were compliant infection control; 68% of hospitals were compliant to Availability of Medicines and
Supplies; and 86% of hospitals were compliant to waiting times4.
The NDoH conceptualised the Ideal Clinic Realisation and Maintenance (ICRM) programme in response to the
weaknesses in the quality of primary health care (PHC) services identified by the Office of Health Services
Compliance (OHSC) in 2013. Operation Phakisa was launched in November 2014 to rapidly scale up the Ideal
Clinic Model across all PHC facilities. In 2015 the ICRM programme was officially launched. The main intention
of the ICRM programme was to enhance the PHC system towards achieving the goals of universal health
access to a high quality of care.
2 World Health Organisation. International Non-proprietary names, 2016. http://www.who.inc/medicines/services/inn/en/
SECTION 2 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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AN ‘IDEAL CLINIC’ IS:
• a clinic with good infrastructure (i.e. physical condition and spaces, essential equipment, and information and communication tools), adequate staff, adequate medicines and supplies, good administrative processes, and adequate bulk supplies;
• and such a clinic uses applicable clinical policies, protocols and guidelines, as well as partner and stakeholder support, to ensure the provision of quality health services to the community5.
THE ICRM HAS RESULTED IN THE FOLLOWING BENEFITS TO THE HEALTH SYSTEM:
• Improved oversight on the status of clinics
• Data immediately available on equipment and infrastructure status of all clinics-thus able to quantify needs and related costs
• Serves to motivate staff at clinics and district officials to improve facility status and service delivery
The successful implementation of the ICRM programme created the impetus to extend the goals of universal
health access, cost effective and efficient services of a high quality and standard by creating a similar
framework for Ideal hospitals as the Ideal Clinic framework.
SECTION 2 BACKGROUND: INTEGRATED HEALTH SERVICE DELIVERY PLATFORM
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BACKGROUND: INTEGRATED HEALTH SERVICE DELIVERY PLATFORMThe attainment of improved health outcomes, universal health coverage and overall improved quality of
health requires an integrated and seamless healthcare delivery system supported by strengthening of the
health system building blocks.
The Health Service Delivery Platform is an expression of the organisation of the various parts that make up
a well-functioning health system. The purpose of the Health Service Delivery Platform as defined for South
Africa is to improve the overall quality of care delivered by the health system moving towards the provision
of Universal Health Coverage and the attainment of improvement of health outcomes such that we realise the
NDP2030 goals of Health for All.
Figure 1: Integrated healthcare service delivery platform
The Health Service Delivery Platform coherently indicates the relationships between the core health services,
support services (linked to WHO Health System Building Blocks) and linkages which contribute to the overall
functioning and synchronisation of the health services.
CORE HEALTH SERVICES
LIN
KAGE
SER
VICE
S
SUPPORT SERVICES
EMERGENCY MEDICAL SERVICES
MEDICINE SUPPLIES
(Therapeutic services)
DIAGNOSTIC AND PARA-CLINICAL SERVICES
CLINICAL SERVICES IN
HEALTH FACILITIES
COMMUNITY BASED
SERVICES (CHWs,
School Healh, Environmental
Health)
Management and Administrative Processes
Finance and Supply Chain Management
Human Resources Management and Legal Services
Infrastructure (buildings, equipment, ICT)
Information Management
Security Services
Leadership, Governance and Community Participation
QUA
LITY
COLL
ABO
RATI
ON
COM
MU
NIC
ATIO
N
TRAI
NIN
GINTEGRATED REFERRAL SYSTEM
SECTiON
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SECTION 2 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Core Health Services
Community based services: this consists of services that are delivered within the community setting towards
addressing population health issues, responding to the SDGs (sustainable development goals) ,improving
self- management of patients with chronic conditions and identifying neglected persons with disabilities and
the elderly. These services are delivered through Ward Based Outreach PHC teams, Integrated School Health
Teams and Environmental Health officers. The services delivered include health education, health promotion
and screening, prevention of disease, adherence support and de-hospitalised care comprising chronic care,
sub-acute care, palliative care, mental health care and home-based care.
Facility based clinical services: Primary healthcare (PHC) clinics are the first point of contact with the formal
healthcare system. Patients may present to the PHC clinic with any health care requirement (whether for
promotive, preventive, curative; rehabilitative, palliative or community-based mental health) and will either
receive the care they need at this level or will be referred to a hospital if more specialised services are
necessary. District Hospitals are the highest level of support within the District Health System and thus
perform a gatekeeper role in supporting primary healthcare clinics on the one hand and being a gateway to
more specialist care (Figure 2).
Figure 2: District Health System
A hierarchical relationship exists between the various levels of hospitals as per defined packages of service.
Specialised, Regional (Level 2), Tertiary (Level 3) and Central (level 4) hospitals provide specialist and sub-
specialist services (Regulation R1856) (Table 1). Patients are referred from district hospitals to regional
hospitals then to Provincial tertiary hospitals and if required, to National Referral Hospitals and Central
Hospitals depending on the care and intervention required for an individual (Figure 3).
DCSTs
Health campaigns
Environmental health
Ward-based PHC outreach
School health
Specialist hospital care
Diagnostic services
Research institutions
Provincial support
Social services
Research councils
Specialist NCD care
Mental health unit
MDR-TB controlGood governance
LeadershipManagement
EMS and ambulatory transport
Emergencies
Obstetrics
Surgery
Training
Imaging
Laboratories
PHC FacilitiesQuality
ComprehensivePerson-centred care
Contracted service
providers
Universities
NGO services
SECTION 2 BACKGROUND: INTEGRATED HEALTH SERVICE DELIVERY PLATFORM
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Table 1: Classification of Hospitals
DISTRICT HOSPITAL
REGIONAL HOSPITAL
TERTIARY HOSPITAL
CENTRAL HOSPITAL
SPECIALISED HOSPITAL
Serves a defined population within a health district and support primary health care
Has between 200 and 800 beds
400 and 800 beds A maximum of 1200 beds Has a maximum of 600 beds
Provide a district hospital package of care on a 24 hour basis
Offers services to a defined regional drainage population, limited to provincial boundaries
May provide training for health care service providers
Must provide training of health care providers; conduct research; and must be attached to a medical school as the main teaching platform
Have general practitioners and clinical nurse practitioners primary health services
Receives referrals from several district hospitals; provides short-term ventilation in a critical care unit; and where practical, provide training for health care service providers.
Receives referrals from regional hospitals not limited to provincial boundaries.
Receives patients referred to it from more than one province;
Receives patients referred to it from other levels of care
May only provide the following specialist services- (a) paediatric health services; (b) obstetrics and gynaecology; (c) internal medicine; (d) general surgery; (e) family physician.
Provides health services in the fields of internal medicine, paediatrics, obstetrics and gynaecology, and general surgery; and in at least one of the following specialties namely; orthopaedic surgery; psychiatry; anaesthetics; diagnostic radiology; trauma and emergency services
Provides specialist level services provided by regional hospitals; provides intensive care services under the supervision of a specialist or specialist intensivist
Provide tertiary and central referral services and may provide national referral services
Provides specialised health services like psychiatric services, tuberculosis services, infectious diseases and rehabilitation services
Source NDoH- Regulation R185
Diagnostic and para-clinical services refer to the
branches of medicine comprising the laboratory
sciences (microbiology, chemical pathology,
pathology, haematology,virology) and radiology.
These services assist the health professionals in
making or confirming a diagnosis for an individual
patient.
Para-clinical services include toxicology,
pharmacology and forensic pathology that further
enhance patient management.
Therapeutic services/medicine supplies relates
to the consistent availability and management of
medicines, blood and blood products ,medical
and surgical consumables and, assistive devices
including orthotics and prosthetics.
Emergency Medical Services comprise ambulance
services, aeromedical services and planned patient
transport (PPT) services and is a critical component
of the core health services as it relates to the
movement of patients between facilities as well as
from communities based on need with support by
trained health support staff.
Ambulance Services are required to transfer
acutely ill patients between their homes and the
nearest appropriate level of health facility as well as
between the various levels of facilities (inter-hospital
transfers).
Aeromedical services provide an air service to
transport acutely ill/trauma injury patients with life
threatening issues from distant referring centres to
tertiary or central hospitals.
Planned patient transport (PPT) services are
provided for all non-emergency patients referred for
consultation from one health institution to another
institution that is a significant distance away. This is
to ensure that patients reach their referral hospital
by the appointment time and because of scarce skills
that cannot be located at all centres yet patients
have to be given the opportunity to benefit from the
specialist skill.
SECTION 2 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Referral system is a cross cutting feature of the
service delivery platform that underpins the efficient
and effective functioning of the health system in an
orderly manner. This means that patients receive
optimal care at the appropriate level of health
facility level through access to appropriate specialist
services, without unnecessarily overburdening
the health facility especially at higher levels by
inappropriate conditions being seen there. The
efficient functioning of the referral system relies
on all services being made accessible to correctly
screened patients and moved to a higher/lower
level of care based on clinical condition and clearly
defined referral pathways.
Figure 3: Services across different levels within Health Service Delivery Platform
The management and administration processes; finance and
supply chain management, human resources management,
legal services, infrastructure and health information
systems are inter-related corporate support services, which
must function optimally in order for core health services
to be efficient and effective. Each of these blocks needs
to recognise the interdependence between their roles, and
responsiveness to core health service requirements and
quality of care delivered.
Leadership, governance and community participation are
critical constituents to hold management accountable to
higher structures but most importantly, in a social service
setting to the communities /public at large.
Support Services (linked to WHO Health System Building Blocks)
• Management and Administrative
Services
• Finance and Supply Chain Management
• Human Resources Management and
Legal Services
• Infrastructure (buildings, equipment
and ICT)
• Information Management Services
• Security Services
• Leadership, Governance and
Community Participation
SECTION 2 BACKGROUND: INTEGRATED HEALTH SERVICE DELIVERY PLATFORM
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Linkage services
Training or human resource development (HRD) is a
cross cutting support function for both core health
services as well as support services. This refers to all
levels of training i.e. undergraduate, postgraduate as
well in-service training. Thus, it requires:
• A relationship between academic institutions
that produce the various cadres of health
and health related professionals as well as
other categories of professionals /technicians
/artisans that are required for a fully
functional health system.
• A knowledge management system to
enhance evidence based healthcare towards
improved quality of care.
Communication between internal and external
stakeholders (communities, private health sector,
non-governmental organisations, community-based
organisations, other government agencies) are
essential to have an active, informed and participatory
citizenry that engages with the health system.
Collaboration is key to the success of the health
system in that it relates to both internal and
external working together. Internal collaboration
means that within the health system there is a clear
understanding of how the various facility levels
should work together effectively to deliver seamless
services. External collaboration refers to the various
external stakeholders who impact on the functioning
of the health system e.g. communities, private health
sector, non-governmental organisations, community-
based organisations, other government agencies,
academic institutions, training institutions, service
providers .
Quality
The effective and efficient functioning of the Health
Service Delivery Platform is anticipated to improve
the quality of services delivered at the different levels
of the health system with overarching improvement
in health outcomes at a population level.
Figure 4: Components of the Hospital Package of Services
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IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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IDEAL HOSPITAL
An Integrated People-centred Health Services approach that encompass a continuum of care of health
promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care
services, through the different levels and sites of care within the health system, over the different stages
in the lifecycle of a person will be adopted. Clinical services will be organised in terms of 24-hour services
(emergency health services, obstetric and in-patient services) and eight hour services (ambulatory health
services to outpatients (ideally on referral from a lower level of care), obstetric services, health support
services, rehabilitation and palliative care services, diagnostic and therapeutic services). Integrated Clinical
Services Management framework using the four streams of care is the platform for providing ambulatory
services.
AN ‘IDEAL HOSPITAL’ IS A HOSPITAL WITH:
• Good infrastructure (i.e. physical condition and spaces, health technology, information and communication technology, adequate bulk supplies, and an appropriately managed and maintained motor vehicle fleet)
• Efficient patient administrative processes
• Adequate and appropriately managed staff
• Provides evidence based clinical, therapeutic and diagnostic services consistent with the defined Package of services
• Uses patient experiences, communication and information for continuously improving quality of clinical care, optimisation of hospital processes, finance, system and risks mitigation and management
• Complies with highest standards of corporate governance and is accountable to the community, internal and external stakeholders.
SECTiON
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SECTION 3IDEAL HOSPITAL
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Ideal Hospital Components and Subcomponents
In order to realise and sustain an Ideal Hospital status, a number of components need to be in place and
functioning well. These components relate to patient services and support systems and include:
Each of these components have a number of sub-components, which in turn consists of elements that need
to be realised in order to attain and sustain an “IH” status.
Figure 5: IHRM-F Components and Sub components
1 ADMINISTRATION
2 CLINICAL SERVICES
3 CLINICAL
GOVERNANCE
4 DIAGNOSTIC AND
THERAPEUTIC SERVICES
5 HUMAN
RESOURCES FOR HEALTH
6 SUPPORT SERVICES
7 INFRASTRUCTURE
8 OPERATIONAL MANAGEMENT
9 GOVERNANCE
IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTION 4
PURPOSE OF THE MANUAL
THE IDEAL HOSPITAL MANUAL SERVES THE FOLLOWING PURPOSES:
• To assist managers at various levels of healthcare service provision to correctly interpret and understand the requirement for achieving the elements as depicted in the Ideal Hospital dashboard.
• As a reference, document which guides the managers to determine the status of Ideal Hospital dashboard elements in a facility.
• To be of particular use to the multidisciplinary team that will be responsible for conducting the assessments across all service areas.
• a useful tool for managers at district, provincial and national level to ensure progressive discipline of those reporting to them.
SECTiON
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SECTION 5ABOUT THE MANUAL
ABOUT THE MANUALThe Ideal hospital framework was developed primarily for District
Hospitals with the aim of expanding to Regional and Tertiary
Hospitals. In view of the generic requirements of many of the
elements, it is proposed that the Ideal Hospital framework serve as
a minimum requirement for Regional Hospitals and the framework
be developed incrementally.
The Ideal Hospital Manual provides detailed steps
on how to assess and achieve every element of the
framework. The numbering of the steps is aligned to
the numbering in the dashboard. In some instances,
a step refers the reader to a specific checklist. This
implies that the relevant checklist be used for further
guidance to assess the element.
DOCUMENTS, POLICIES, GUIDELINES AND
STANDARD OPERATING PROCEDURES REFERENCED
AS BEING AVAILABLE ON THE WEBSITE OF THE
NATIONAL DEPARTMENT OF HEALTH
(www.health.gov.za).
SECTiON
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IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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ASSESSMENT METHODOLOGYIn order to undertake a successful assessment, each hospital should select a defined one week period during
which to conduct the assessment. A multidisciplinary team, consisting of clinical service providers, health
supportive services, diagnostic and para-clinical services should be constituted. The tasks should be divided
amongst the team in order to complete the assessment within a single week.
Key and description of measurement
KEY METHOD OF MEASUREMENT
Check applicable documents e.g. policies, guidelines, standard operatingprocedures, data, etc.
Ask staff members and/or clients for their views or level of understanding
Objective observations and/or conclusion
Key and description for level of responsibilityKEY LEVEL OF RESPONSIBILITY
NDoH National Department of Health
P Provincial Department of Health
D District
H Hospital
EHS Environmental Health Services
SECTiON
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SECTION 6METHODOLOGY TO CONDUCT THE ASSESSMENT
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Functional areas to be assessed
Refer to the service areas at which compliance to the element will be assessed.
EMERGENCY HEALTH SERVICES
Accident & emergency unit
EMERGENCY HEALTH SERVICES Obstetrics unit
INPATIENT SERVICES Male ward
INPATIENT SERVICES Female ward
INPATIENT SERVICES Paediatric ward
INPATIENT SERVICES Maternity ward
INPATIENT SERVICES Nursery
INPATIENT SERVICES Medical ward
INPATIENT SERVICES Surgical ward
INPATIENT SERVICES Intensive Care/High Care
INPATIENT SERVICES Theatre
AMBULATORY HEALTH SERVICES Acute
AMBULATORY HEALTH SERVICES Chronic
AMBULATORY HEALTH SERVICES Obstetric unit
HEALTH SUPPORT SERVICES Oral health Services
HEALTH SUPPORT SERVICES Physiotherapy
HEALTH SUPPORT SERVICES Occupational therapy
HEALTH SUPPORT SERVICES
Nutritional support (Dietetics)
HEALTH SUPPORT SERVICES Speech therapy
HEALTH SUPPORT SERVICES Social work
HEALTH SUPPORT SERVICES Eye health
HEALTH SUPPORT SERVICES Podiatry
HEALTH SUPPORT SERVICES Audiology
HEALTH SUPPORT SERVICES
Medical orthotics and prosthetics
HEALTH SUPPORT SERVICES
Rehabilitative and Palliative Care
DIAGNOSTIC AND THERAPEUTIC
SERVICES/PARACLINICAL
Radiology
DIAGNOSTIC AND THERAPEUTIC
SERVICES/PARACLINICAL
Pharmacy
DIAGNOSTIC AND THERAPEUTIC
SERVICES/PARACLINICAL
Laboratory
PATIENT SUPPORT SERVICES Food Services
PATIENT SUPPORT SERVICES CSSD
PATIENT SUPPORT SERVICES Laundry
PATIENT SUPPORT SERVICES Mortuary
HOSPITAL CORPORATE SERVICES Executive Management
HOSPITAL CORPORATE SERVICES
Administration/reception services
HOSPITAL CORPORATE SERVICES Systems management
HOSPITAL CORPORATE SERVICES
Supply chain management
HOSPITAL CORPORATE SERVICES Financial management
HOSPITAL CORPORATE SERVICES
Human Resource management
HOSPITAL CORPORATE SERVICES Infrastructure
HOSPITAL CORPORATE SERVICES Management offices
SECTION 6 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Scoring of the hospital against the elements
Score the performance in line with three colours as follows:
The method of measurement (indicated with symbols), level of responsibility (facility, district, province or
national) and weight (vital, essential and important) is indicated for each element as well as the availability
of a checklist.
Weighting of Ideal Hospital elementsThe weighting of the IHRM-F elements are according to three categories: vital, essential and important.
ACHIEVED PARTIALLY ACHIEVED
NOT ACHIEVED
Extremely important (vital) elements that require immediate
and full correction. These elements affect direct service delivery to and clinical care of patients and without which there may be immediate and long-term adverse effects on the
health of the population.
Very necessary (essential) elements that require resolution within a given time period. These process and structural elements indirectly affect the quality of clinical care given to patients.
Significant (important) elements that require resolution within a given time period. These
are process and structural elements that affect the quality of the
environment in which healthcare is given to patients.
VITALIMPORTANT
NBESSENTIAL
SECTION 6METHODOLOGY TO CONDUCT THE ASSESSMENT
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The average hospital score against all components, each component, all sub-components and each sub-
component will be calculated and be depicted. The status of the hospital will be determined when the
minimum average percentages for Vital, Essential and Important elements have also been achieved. It is
therefore important to note that a facility can obtain a high average score (70 to 99 percent) but still fail to
obtain an Ideal Hospital category as they have failed to obtain the minimum average score for per weight
category.
Over time, as the quality of the conditions of PHC facilities improve, we may add more elements and more
specifications for certain elements
Weights Silver Gold Platinum
Vital 90% 100% 100%
Essential 70% 80% 90%
Important 65% 75% 85%
NO CATEGORY ACHIEVED
SILVER (90% for vital;
70% for essential and 65% for important)
GOLD (100% for vital;
80% for essential and 75% for important)
PLATINUM (100% for vital;
90% for essential and 85% for important)
SCORING – CHECKLIST
Each item in the checklist is scored in column for score mark as follows:
Y (Yes) = if present = 1
N (No) = if not present = 0
NA (Not applicable) = for small facilities or where certain services are not rendered.
A total percentage will be calculated for each checklist and this will be converted into a decimal.
SCORING – ELEMENTS
Each item in the elements that have no checklist is scored in column for score mark as follows:
Y (Yes) = if present
N (No) = if not present
NA (Not applicable) where Y = 1 and N = 0
Determination of hospital status
Depending on how a facility performs in a status determination, the facility will be categorised as:
IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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ASSESSING IDEAL HOSPITAL COMPONENTS AND SUBCOMPONENTSThe weighting of the IHRM-F elements, method of measurement, level of responsibility, whether they have a checklist, and performance for each element are indicated in the table below.
SECTiON
7
SECTION 7IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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SECTION 3 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTION 3IDEAL HOSPITAL
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SECTION 3 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTION 3IDEAL HOSPITAL
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SECTION 7 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTION 7IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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SECTION 7 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTION 7IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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SECTION 7 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTION 7IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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SECTION 7 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTION 7IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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SECTiON
8
ASSESSMENT OF IDEAL HOSPITAL ELEMENTS
Component 1: Administration
Sub-component 1: Signage and notices
COMMITMENT FOR SUB-COMPONENT 1Monitor whether there is communication about the facility and the services provided.
Systems manager
ELE
ME
NTS
NB 1 Geographical location signage from main roads in place
NB 2 All external signage is in place
NB 3 Facility information board visibly displayed at the entrance of the premises
NB 4 Disclaimer signs visibly displayed at entrance of hospital
NB 5 The vision, mission and values of the hospital are visibly displayed
NB 6 Patients’ Rights Charter is displayed in all clinical service areas in at least two local languages
NB 7 Hospital management organogram with contact details of the hospital managers are displayed on a
central notice board
NB 8 Contact details of the Hospital Board are visibly displayed
NB 9 All service areas within the hospital are clearly signposted
Vital Essential NB Important
Who is responsible for this sub-component?
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Element 1: Geographical location signage from main roads in place RE
SPO
NSIBLE PERSON
The systems manager must familiarise themselves with the external signage requirements.
Signboards must be available that provide directions to the hospital on each main road-between 2km and 5 km.
The boards must be clearly visible with no obstructions.
REVIEWER Observe that there are external signage on all main roads leading to the facility and verify that the signage boards are clearly visible.
CHECKLIST FOR ELEMENT 1
GEOGRAPHICAL LOCATION SIGNAGE FROM MAIN ROADS
Description Score
a. Both directions on each main road
b. Within 2 km of hospital
c Within 5 km of hospital
d. No obstructions to visibility
Total score
Total maximum possible score
Percentage score %
Element 2: All external signage is in place
RESP
ONS
IBLE PERSON External signage must be clearly visible within the hospital indicating waste storage areas, staff and patient parking areas, ambulance loading and off loading zones and helicopter landing pads, emergency assembly points, and healthcare and general waste storage areas.
REVIEWER Observe that the external signage in the hospital is clearly visible and indicates waste storage areas, staff and patient parking areas, ambulance loading and off loading zones and helicopter landing pads, emergency assembly points, and healthcare and general waste storage areas.
CHECKLIST FOR ELEMENT 2
ALL EXTERNAL SIGNAGE IS IN PLACE
Description Score
a. Vehicles and persons will be searched
b. Entry and parking are at own risk
Specific external locations:
a. Emergency Assembly Point
Waste storage:
a. Healthcare Risk Waste (medical waste)
b. Healthcare General Waste
At or near to main entrance of building:
a. Ambulance parking sign OR Ambulance parking area marked on paving
b. Helicopter landing pad area sign or marked on paving
c. Staff parking sign or parking area marked on paving
Total score
Total maximum possible score
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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NB Element 3: Facility information board visibly displayed at the
entrance of the premises
RESP
ONS
IBLE PERSON
The facility information board must be on the wall next to the main entrance of the facility building or on a freestanding board approximately 500mm to 2000 mm before the main entrance to the facility building (entrance of the premises).
The facility information board must provide name of hospital, contact details, operating hours and emergency contact details.
REVIEWERObserve that the hospital information board is available at the hospital entrance and has at minimum name of hospital, contact details, operating hours and emergency contact details.
CHECKLIST FOR ELEMENT 3
FACILITY INFORMATION BOARD VISIBLY DISPLAYED AT THE ENTRANCE OF THE PREMISES
Description Score
a. Name of hospital
b. Contact details
c. Operating hours
d. Package of Services offered
e. Visiting hours
f. Emergency contact details
Total score
Total maximum possible score
Percentage score %
NB Element 4: Disclaimer signs visibly displayed at entrance of hospital
RESP
ONS
IBLE PERSON A disclaimer notice must be displayed at the entrance of the hospital either separately or on the main hospital information boards and amongst others contain notices for littering, loitering, smoking, alcohol, fire-arms and liability.
REVIEWERObserve whether there is disclaimer notices available at the entrance of the facility and contain notices for littering, loitering, smoking, alcohol, fire-arms and liability.
CHECKLIST FOR ELEMENT 4
DISCLAIMER SIGNS VISIBLY DISPLAYED AT ENTRANCE OF HOSPITAL
Description Score
No animals except service animals allowed
No littering
No weapons
No smoking
No alcohol allowed
No vendors
Laibility statement
Total score
Total maximum possible score (sum of all scores minus those marked NA)
Percentage score %
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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NB Element 5: The vision, mission and values of the hospital are visibly
displayedRE
SPO
NSIBLE PERSON The vision, mission and values of the hospital must visibly displayed on a notice board
surface at the main entrance, hospital management offices, outpatients, accidents and emergency and obstetric units.
REVIEWERObserve whether vision, mission and values of the hospital is visibly displayed on a notice board surface at the main entrance, hospital management offices, outpatients, accidents and emergency and obstetric units.
There is no checklist for this element
NB Element 6: Patients’ Rights Charter is displayed in all clinical service
areas in at least two local languages
RESP
ONS
IBLE PERSON Download the Patient’s Right Charter from www.doh.gov.za.
Display the Patient’s Right Charter in two languages in all clinical service areas.
REVIEWERObserve whether the Patient’s Right Charter is displayed in the service areas listed here:
NB Element 7: Hospital management organogram with contact details
of the hospital managers are displayed on a central notice board
RESP
ONS
IBLE PERSON
Display the officially approved Hospital Management organogram with contact details at the management offices and the main reception area.
REVIEWERObserve whether the Hospital Management organogram with management contact details is displayed at the management offices and the main reception area.
There is no checklist for this element
Accident & emergency unit
Obstetrics unit
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive care/high Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Oral health services
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and palliative care
Radiology
Pharmacy
Laboratory
Executive Management
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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NB
Element 8: Contact details of the Hospital Board is visibly displayed
RESP
ONS
IBLE PERSON
Display the contact details of the hospital board at the management offices and the main reception area. This should be for the current board and updated in the last year.
REVIEWERObserve whether the Contact details of hospital boards are displayed at the management offices and the main reception area. Check whether the details of the hospital board is current.
There is no checklist for this element
NB Element 9: All service areas within the hospital are clearly
signposted
RESP
ONS
IBLE PERSON
All service areas within the hospital are clearly signposted so that patient is able to locate the different services.
REVIEWER
Observe whether the signage in all service areas is clearly signposted for administration services (Help desk/Reception/Complaints); Hospital Management offices; Emergency exits; Entrances and Exits; Patient toilets; Directional signage for service areas; Functional areas and Support areas. Checklist 9 is separated to cater for Ambulatory Services; Inpatient Services; Health support and Corporate Services.
CHECKLIST FOR ELEMENT 9 A Emergency Health Services
Ambulatory Health Services
ALL SERVICE AREAS WITHIN THE HOSPITAL ARE CLEARLY SIGNPOSTED
Acc
iden
t &
E
mer
gen
cy
Ob
stet
rics
Acu
te
Chr
oni
c
Ob
stet
ric
Syst
ems
man
agem
ent
Description Score Help Desk/reception
Complaints/suggestions/compliments box Emergency room Hospital management offices Emergency exit(s) Exit(s) Stairs (if applicable)
Patient Toilets a. Directional arrows to toilets b. Disabled toilet pictogram c. Female toilet pictogram d. Male toilet pictogram e. Disability toilet pictogram
Directional signs for service areas Accident and emergency unit Maternity unit Outpatient Medical ward
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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CHECKLIST FOR ELEMENT 9 A Emergency Health Services
Ambulatory Health Services
ALL SERVICE AREAS WITHIN THE HOSPITAL ARE CLEARLY SIGNPOSTED
Acc
iden
t &
E
mer
gen
cy
Ob
stet
rics
Acu
te
Chr
oni
c
Ob
stet
ric
Syst
ems
man
agem
ent
Description Score Surgical ward Paediatric Ward Nursery Operating theatres Physiotherapy Occupational therapy Dietetics Radiology Speech therapy & audiology Optometry Social worker Oral health Mental health Medical orthotics Pharmacy Food services Laundry CSSD Mortuary Patient transport Registry Stores Laboratory
Functional room signage (each area/room should be labelled)
Consulting rooms Wards
Fire-fighting signs: At each hose, fire hose pictogram At each extinguisher, fire extinguisher pictogram
Support/admin areas (room name sign on each door) Storeroom(s) Sluice Patient records storage room Staff toilet(s) Boardroom/training room Staff room Boiler Room Maintenance
Total score
Maximum possible score
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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CHECKLIST FOR ELEMENT 9 B Inpatient Services
ALL SERVICE AREAS WITHIN THE HOSPITAL ARE CLEARLY SIGNPOSTED
Med
ical
war
d
Surg
ical
war
d
Pae
dia
tric
War
d
Mat
erni
ty w
ard
Nur
sery
Thea
tre
Inte
nsiv
e C
are/
Hig
h C
are
Description Score
Complaints/suggestions/compliments box Hospital Management offices Emergency exit(s) Exit(s) Stairs (if applicable)
Patient Toilets a. Directional arrows to toilets b. Disabled toilet pictogram c. Female toilet pictogram d. Male toilet pictogram e. Disability toilet pictogram
Directional signs for service areas Accident and Emergency unit Maternity unit Outpatient Medical ward Surgical ward Paediatric ward Nursery Operating theatres Physiotherapy Occupational therapy Dietetics Radiology Speech therapy and audiology Optometry Social Worker Oral Health Mental health Medical orthotics Pharmacy Food services Laundry CSSD Mortuary Patient transport Registry Stores Laboratory
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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CHECKLIST FOR ELEMENT 9 B Inpatient Services
ALL SERVICE AREAS WITHIN THE HOSPITAL ARE CLEARLY SIGNPOSTED
Med
ical
war
d
Surg
ical
war
d
Pae
dia
tric
War
d
Mat
erni
ty w
ard
Nur
sery
Thea
tre
Inte
nsiv
e C
are/
Hig
h C
are
Functional room signage (each area/room should be labelled)
Wards Fire-fighting signs:
a. At each hose, fire hose pictogram b. At each extinguisher, fire extinguisher pictogram
Support/admin areas (room name sign on each door)
a. Storeroom(s) b. Sluice d. Staff toilet(s) e. Boardroom/training room e. Staff room
Total score
Maximum possible score
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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CH
EC
KLI
ST F
OR
ELE
ME
NT
9c
Hea
lth
Sup
po
rt S
ervi
ces
Dia
gno
stic
and
th
erap
euti
c se
rvic
es/
par
aclin
ical
Pat
ient
sup
po
rt
serv
ices
Ho
spit
al
Co
rpo
rate
Se
rvic
es
ALL
SE
RV
ICE
AR
EA
S W
ITH
IN T
HE
HO
SPIT
AL
AR
E C
LEA
RLY
SIG
NP
OST
ED
Oral health Services
Physiotherapy
Occupational therapy
Nutritional support (Dietetics)
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and palliative care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Supply chain management
Financial management
Executive Management
Des
crip
tio
nSc
ore
C
om
pla
ints
/su
gg
esti
on
s/co
mp
limen
ts b
ox
E
mer
gen
cy e
xit(
s)
E
xit(
s)
S
tair
s (i
f ap
plic
able
)
Pat
ient
To
ilets
a. D
irec
tio
nal
arr
ow
s to
to
ilets
b. D
isab
led
to
ilet
pic
tog
ram
c. F
emal
e to
ilet
pic
tog
ram
d. M
ale
toile
t p
icto
gra
m
e.
Dis
abili
ty t
oile
t p
icto
gra
m
Dir
ecti
ona
l sig
ns f
or
serv
ice
area
s -
Acc
iden
t an
d E
mer
gen
cy u
nit
Mat
ern
ity
un
it
O
utp
atie
nt
Med
ical
war
d
S
urg
ical
war
d
P
aed
iatr
ic w
ard
Nu
rser
y
O
per
atin
g t
hea
tres
Phy
sio
ther
apy
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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CH
EC
KLI
ST F
OR
ELE
ME
NT
9c
Hea
lth
Sup
po
rt S
ervi
ces
Dia
gno
stic
and
th
erap
euti
c se
rvic
es/
par
aclin
ical
Pat
ient
sup
po
rt
serv
ices
Ho
spit
al
Co
rpo
rate
Se
rvic
es
ALL
SE
RV
ICE
AR
EA
S W
ITH
IN T
HE
HO
SPIT
AL
AR
E C
LEA
RLY
SIG
NP
OST
ED
Oral health Services
Physiotherapy
Occupational therapy
Nutritional support (Dietetics)
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and palliative care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Supply chain management
Financial management
Executive Management
Des
crip
tio
nSc
ore
O
ccu
pat
ion
al t
her
apy
Die
teti
cs
R
adio
log
y
S
pee
ch t
her
apy
and
au
dio
log
y
O
pto
met
ry
S
oci
al w
ork
er
O
ral H
ealt
h
Men
tal h
ealt
h
Med
ical
ort
ho
tics
Ph
arm
acy
Fo
od
ser
vice
s
L
aun
dry
CS
SD
Mo
rtu
ary
Pat
ien
t tr
ansp
ort
Reg
istr
y
S
tore
s
L
abo
rato
ry
Fun
ctio
nal r
oo
m s
igna
ge
(eac
h ar
ea/r
oo
m s
houl
d b
e la
bel
led
)
Co
nsu
ltin
g r
oo
ms
War
ds
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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CH
EC
KLI
ST F
OR
ELE
ME
NT
9c
Hea
lth
Sup
po
rt S
ervi
ces
Dia
gno
stic
and
th
erap
euti
c se
rvic
es/
par
aclin
ical
Pat
ient
sup
po
rt
serv
ices
Ho
spit
al
Co
rpo
rate
Se
rvic
es
ALL
SE
RV
ICE
AR
EA
S W
ITH
IN T
HE
HO
SPIT
AL
AR
E C
LEA
RLY
SIG
NP
OST
ED
Oral health Services
Physiotherapy
Occupational therapy
Nutritional support (Dietetics)
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and palliative care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Supply chain management
Financial management
Executive Management
Des
crip
tio
nSc
ore
Fir
e-fi
ght
ing
sig
ns:
a. A
t ea
ch h
ose
, fire
ho
se p
icto
gra
m
b
. At
each
ext
ing
uis
her
, fire
ext
ing
uis
her
p
icto
gra
m
Sup
po
rt/a
dm
in a
reas
(ro
om
nam
e si
gn
on
each
do
or)
a. S
tore
roo
m(s
)
d
. Sta
ff t
oile
t(s)
e. B
oar
dro
om
/Tra
inin
g r
oo
m
e.
Sta
ff r
oo
m
Tota
l sco
re
Max
imum
po
ssib
le s
core
Per
cent
age
sco
re%
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Component 1: Administration
Sub-component 2: Staff identity and dress code
COMMITMENT FOR SUB-COMPONENT 2Monitor whether staff dress code and mode of staff identification are in accordance with policy prescripts
The hospital corporate services - human resource management.
ELE
ME
NTS
NB 10 There is a prescribed dress code for all service providers
NB 11 All service provider comply with prescribed dress code ?
NB 12 All service roviders wear an identification flag
Vital Essential NB Important
NB Element 10: There is a prescribed dress code for all service providers
RESP
ONS
IBLE PERSON Hospital corporate services - human resource management: Ensure that the hospital has the Staff Dress Code and Insignia specifications from the district/province. The dress code must include all healthcare workers and non-clinical support service (laundry, mortuary, food services, cleaning staff), and administrative staff.
REVIEWERVerify that the HR department has a copy of the prescribed dress code for all categories of staff.
There is no checklist for this element
Who is responsible for this sub-component?
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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NB Element 11: All service providers comply with prescribed dress code
RESP
ONS
IBLE PERSON All staff on duty should have short nails, wear minimal jewellery, and wear pants or skirts that are below the knees. No see-through clothes or open footwear. In addition, the support services staff must wear prescribed uniform; the hair covering and safety shoes. The nurses should wear appropriate devices.
REVIEWER
Randomly select 20 clinical staff members and 10 non-clinical staff members and assess whether they have short nails, wear minimal jewellery, and wear pants or skirts that are below the knees; clothes are not see-through; footwear is closed. In addition, the support services staff must wear prescribed uniform; the hair covering and safety shoes. The nurses should wear appropriate devices.
CHECKLIST FOR ELEMENT 11
ALL STAFF MEMBERS COMPLY WITH PRESCRIBED DRESS CODE (CLINICAL SERVICE PROVIDERS: DOCTORS, NURSE, SUPPORT SERVICES)
Item
Sco
re
Staff
mem
ber
1
Staff
mem
ber
2
Staff
mem
ber
3
Staff
mem
ber
4
Staff
mem
ber
5
Staff
mem
ber
6
Staff
mem
ber
7
Staff
mem
ber
8
Staff
mem
ber
9
Staff
mem
ber
10
Staff
mem
ber
11
Staff
mem
ber
12
Staff
mem
ber
13
Staff
mem
ber
14
Staff
mem
ber
15
Staff
mem
ber
16
Staff
mem
ber
17
Staff
mem
ber
18
Staff
mem
ber
19
Staff
mem
ber
20
Nails short
Jewellery minimal (plain wedding band, small ear rings, no necklaces)Dress/skirt OR pants (dress/skirt should not be shorter than knee length)No see-through clothesTailored clothes (not too tight nor too loose)No open footwear
Distinguishing devices worn
NON-CLINICAL: FOOD SERVICES, MAINTENANCE, LAUNDRY, CSSD, MORTUARY, CLEANERS, SECURITY
Item
Staff
m
emb
er 1
Staff
m
emb
er 2
Staff
m
emb
er 3
Staff
m
emb
er 4
Staff
m
emb
er 5
Staff
m
emb
er 6
Staff
m
emb
er 7
Staff
m
emb
er 8
Staff
m
emb
er 9
Staff
m
emb
er 1
0St
aff
mem
ber
11
Staff
m
emb
er 1
2St
aff
mem
ber
13
Staff
m
emb
er 1
4St
aff
mem
ber
15
Staff
m
emb
er 1
6St
aff
mem
ber
17
Staff
m
emb
er 1
8St
aff
mem
ber
19
Staff
m
emb
er 2
0
Short nails
Jewellery minimal (plain wedding band, small ear rings, no necklaces)
Hair Covering
Prescribed uniformNo open footwear
Safety shoes
Total score Maximum possible score
Percentage score %
?
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NB Element 12: All service providers wear an identification tag
RESP
ONS
IBLE PERSON
All the staff on duty must wear official identification tags.
The tag shall include the following information:
• Emblem of the provincial Department of Health
• Initial/full names and surname of the staff member and staff designation eg: ‘professional nurse’, ‘data capturer’, ‘general assistant’.
REVIEWERRandomly select 10 clinical and 10 non-clinical staff and observe whether the staff has the appropriate identification tags.
CHECKLIST FOR ELEMENT 12
ALL SERVICE PROVIDERS WEAR AN IDENTIFICATION TAG
Staff member
Sco
re
Staff
mem
ber
1
Staff
mem
ber
2
Staff
mem
ber
3
Staff
mem
ber
4
Staff
mem
ber
5
Staff
mem
ber
6
Staff
mem
ber
7
Staff
mem
ber
8
Staff
mem
ber
9
Staff
mem
ber
10
Clinical Non clinical
Total score
Total maximum possible score
Percentage score %
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Component 1: Administration
Sub-component 3: Patient service organisation
COMMITMENT FOR SUB-COMPONENT 3: Monitor the processes that enable responsive patient service
Who is responsible for this sub-component?
Administration/reception services but the application will be across all clinical services areas.
ELE
ME
NTS
NB 13 Help/information desk is available
NB 14 There is a process for patients to be registered and issued with a patient record
NB 15 The uniform patient fee schedule is implemented
16 There is a process for the triaging of patients
NB 17 There is a designated individual responsible for the management of queues
18 There is access for persons with wheelchairs
NB 19 There is a standard operating procedure detailing assistance available for patients with disabilities
20 A functional wheelchair is available
21 There is a standard operating procedure for admission
22 There is a process for relatives/visitors to locate admitted patients at the reception
23 There is a discharge process
24 Clean water and disposable cups are available for patients
Vital Essential NB Important
NB Element 13: Help/information desk is available
RESP
ONS
IBLE PERSON A clearly identified help/information desk located in an area that is accessible to patients entering the hospital building must be available. The help/information desk should be staffed during normal working hours.
REVIEWERObserve that a help/information desk is available’ easily accessible to patients and is staffed.
There is no checklist for this element
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NB Element 14: There is a process for patients to be registered and
issued with a patient recordRE
SPO
NSIBLE PERSON
A well-defined process for patients to be registered and issued with a patient record is documented and is available at the reception/administration area.
REVIEWER
Request to see a copy of the written process for registering patients and issuing of a record. Observe that the process of patient registration and issuing of patient records is in keeping with the written guideline.
There is no checklist for this element
NB Element 15: The uniform patient fee schedule is implemented
RESP
ONS
IBLE PERSON The hospital must have a copy of the current uniform patient fee schedule (UPFS) (available www.health.gov.za). Display the tariff for patients in the patient registration area. Implement th UPFS for all patients accessing hospital services.
REVIEWER Observe whether the UPFS is visibly displayed in the patient registration area. Randomly select 20 records of patients that were discharged in the last three months to assess if UPFS is being implemented.
CHECKLIST FOR ELEMENT 15
THE UNIFORM PATIENT FEE SCHEDULE IS IMPLEMENTED The patient fee schedule is displayed at patient registration
Description ScorePatient category classification
Facility Fee Professional Fees Procedures Proof of
payment
Patient record 1 Patient record 2 Patient record 3 Patient record 4 Patient record 5 Patient record 6 Patient record 7 Patient record 8 Patient record 9 Patient record 10 Patient record 11 Patient record 12 Patient record 13 Patient record 14 Patient record 15 Patient record 16 Patient record 17 Patient record 18 Patient record 19 Patient record 20
Total score
Total maximum possible score
Percentage score %
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Element 16: There is a process for the triaging of patients
RESP
ONS
IBLE PERSON Ensure that there is a documented process for the triaging of patients. The process must prioritise the very sick, frail and elderly patients in the emergency and ambulatory service areas. Each patient waiting area should have notice in at least two local languages indicating the prioritisation process for very sick, frail and elderly patients.
REVIEWER Request to see a copy of the documented process for triaging patients. Interview staff in the emergency and outpatient areas and observe that patients are being triaged appropriately in the relevant clinical service areas listed in the table below.
CHECKLIST FOR ELEMENT 16
THERE IS A PROCESS FOR THE TRIAGING OF USERS
Description Score
There is a protocol for the triaging of patients
Patients are triaged as per protocol
Infants, frail, elderly, and disabled patients are prioritised
Total score
Total maximum possible score
Percentagescore %
NB Element 17: There is a designated individual responsible for the
management of queues
RESP
ONS
IBLE PERSON
Station a queue marshal or designated staff member at the Accident and Emergency, and Ambulatory Health Services, to guide patients the respective waiting areas.
REVIEWER Observe that each of the clinical service areas has a designated person managing the queue.
There is no checklist for this element There is no checklist for this element
CHECK IN THESE
FUNCTIONAL AREAS
Accident & emergency Maternity ward
Ambulatory health services (acute, chronic, obstetric)
CHECK IN THESE
FUNCTIONAL AREAS
Accident & emergency
Ambulatory health services (acute, chronic, obstetric)
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Element 18: There is access for persons with wheelchairsRE
SPO
NSIBLE PERSON
The design of the hospital should allow for persons with wheelchairs to access all service areas. Ensure that the Main entrance; Accident and Emergency; Outpatients; Health Support Area; Inpatient areas and Maternity Unit has a ramp to allow access for persons with wheelchairs unless the entrance to the facility has no incline. Handrails and elbow taps must be available in bathrooms for patients for patients with disabilities.
REVIEWERObserve that each service area has access for persons with wheelchairs in the areas listed in the Table below.
CHECKLIST FOR ELEMENT 18
THERE IS ACCESS FOR PERSONS WITH WHEELCHAIRS
Description Score
Ramp to allow access for persons with wheelchairs unless the entrance to the facility has no incline
Ramp has handrails unless the entrance to the facility has no incline
Elbow taps in toilet with access for persons with wheelchairs
Toilets has access for persons with wheelchairs
In the toilet/s with access for persons iwith disabilities, door handles are at the height of a wheelchairs
Handrails are installed In the toilet/s with access for persons with wheelchairs
Total score
Total maximum possible score
Percentage score %
Accident & emergency unit
Obstetrics unit
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive care/high Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Oral health services
Physiotherapy
Occupational therapy
Nutritional support (Dietetics)
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Administration/reception services
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 19: There is a standard operating procedure detailing
assistance available for patients with disabilities
RESP
ONS
IBLE PERSON Ensure that the facility has a standard operating procedure that details the assistance available for patients with disabilities. The standard operating procedure must indicate assistance that in terms of dressing, bathing, transferring between beds and wheelchairs.
REVIEWERRequest to see a copy of the standard operating procedure that details the assistance available for patients with disabilities Interview a staff member to explain the process of how patients with disabilities are assisted.
There is no checklist for this element
Element 20: A functional wheelchair is available
RESP
ONS
IBLE PERSON A functional wheelchair must be available for all ambulatory health service areas. Emergency health services should have a designated wheelchair that must be available 24 hours a day. Inpatient services can share wheelchairs
REVIEWER
Check that a functional wheelchair is available in areas listed below.
Accident & emergency unit
Obstetrics unit
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive care/high Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (Dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Administration/reception services
CHECK IN THESE
FUNCTIONAL AREAS
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Element 21: There is a standard operating procedure for admissionRE
SPO
NSIBLE PERSON
There must be documented process for admission of a patient. The SOP should include the relevant documentation to be completed, booking of beds and contacting relevant wards. The process for a caregiver accompanying a minor who is being admitted must be clearly documented. Each ward must have an admission/discharge register in which the patient’s details including: patient name, identification number, and diagnosis are recorded.
REVIEWERRequest a copy of the documented process. Verify that the SOP is implemented, by asking a staff member to explain the admission process. Check the admission/discharge register in randomly selected wards.
Checklist 21
CHECKLIST FOR ELEMENT 21A Inpatient Services
THERE IS A STANDARD OPERATING PROCEDURE FOR ADMISSION
Med
ical
war
d
Su
rgic
al w
ard
Mat
ern
ity
war
d
Inte
nsi
ve C
are/
Hig
h
Car
e
Ad
min
istr
atio
n/
rece
pti
on
ser
vice
s
Description Score
Standard operating procedure available
Process for caregiver staying with admitted child
Total score
Maximum possible score
Percentage score %
CHECKLIST FOR ELEMENT 21A
THERE IS A STANDARD OPERATING PROCEDURE FOR ADMISSION
Pae
dia
tric
War
d
Nu
rser
y
Ad
min
istr
atio
n/
rece
pti
on
ser
vice
s
Description Score
Standard operating procedure available
Process for caregiver staying with admitted child
Total score
Maximum possible score
Percentage score %
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Element 22: There is a process for relatives/visitors to locate admitted patients at the reception
RESP
ONS
IBLE PERSON There is a documented process that is visibly displayed at the help/information desk as well as registration area that explains to relatives the process for locating admitted patients. The reception office must keep a register of admissions, which must include the patient identification details and which ward the patient have been admitted to.
REVIEWERRequest a copy of the documented process for location of admitted patients by relatives. Check that there is a register for relatives/visitors to locate admitted patients at the reception office.
There is no checklist for this element
Element 23: There is a discharge process
RESP
ONS
IBLE PERSON The hospital must have guidelines for the discharge of patients. The guidelines must include that the patient’s date of discharge must be recorded in the ward admission/discharge; and that a relative/next of kin be notified of the discharge; planned patient transport be arranged if the patient is being transferred to another facility.
REVIEWER Request to a see these guidelines are available and ask a staff member to explain the discharge process. Check the admission/discharge register in randomly selected wards.
There is no checklist for this element
Element 24: Clean water and disposable cups are available for patients
RESP
ONS
IBLE PERSON
The hospital must provide clean water in water dispensers and disposable cups for patients in all clinical service areas.
REVIEWER Open all taps in the various clinical service areas to see if water is available and looks drinkable. Verify that there are disposable cups present at the drinking taps. Areas to be assessed are listed in the table below.
Accident & emergency unit
Obstetrics unit
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Administration/reception services
CHECK IN THESE
FUNCTIONAL AREAS
CHECKLIST FOR ELEMENT 24
CLEAN WATER AND DISPOSABLE CUPS FOR PATIENTS
Description Score
Clean water is available
Disposable cups is available
Total score
Total maximum possible score
Percentage score %
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Component 1: Administration
Sub-component 4: Management of patient records
COMMITMENT FOR SUB-COMPONENT 4: Monitor whether patients’ records content is systematically organised using prescribed stationery and that the patient records are managed appropriately.
Administration and reception services (the application will be across all clinical services)
ELE
ME
NTS
NB 25 The SOP/guideline for managing of patient records is adhered to
NB 26 Clinical and administrative stationery is available in sufficient quantities
NB 27 There is a single patient folder irrespective of health conditions and services accessed
28 Patient record is fully completed
29 Maternity Case Record is fully completed
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 25: The SOP/guideline for managing of patient records is
adhered to
RESP
ONS
IBLE PERSON Ensure that the hospital has a documented SOP/guideline for managing patient records that includes details of the criteria of the storage room; filing system and access to patient records.
REVIEWER Request to see the documented SOP/guideline for managing patient records. To verify that the SOP is implemented, conduct a walk through to the record storage room and ask a staff member to explain how patient records are filed and accessed.
CHECKLIST FOR ELEMENT 25
SOP/GUIDELINE FOR MANAGING PATIENT RECORDS IS AVAILABLE
ITEM
The SOP/guideline for filing, archiving and disposal of patient records is available Score
Patient record storage room adheres to the following:
Lockable with a security gate OR electronically controlled entrance (tag)
Shelves OR cabinets to store files
Lowest shelf OR cabinets start at least 100 mm off the floor and the top of shelving is not less than 320 mm from the ceiling to allow airflow
Aisle and shelves OR Cabinets labelled correctly according to SOP
Counter or sorting table or dedicated shelves to sort files
Light is functional and allows for all areas of the room to be well lit
Room is clean and dust free
Filing system for patient records adheres to the following:
Standardised unique record registration number is assigned to files.
Record registration number is clearly displayed on the cover of the patient record
All patient records are filed as per SOP
A tracking system is in place at to check that all outpatient records issued for the day are returned to the patient records storage room/registry by the end of the day
Annual register available of archived records
Annual register available of disposed records
A destruction certificate of disposed records are available
Access for patient to their records
There is a process for patients to access a copy of their health record
Total score
Maximum possible score
Percentage score %
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NB Element 26: Clinical and administrative stationery is available in
sufficient quantitiesRE
SPO
NSIBLE PERSON Printing stationery for the facility must be available at all times. The facility
must determine and document their minimum required stationery. The hospital administrative staff must conduct a stock-take on a weekly basis and order the required stationery through the Provincial procurement processes.
REVIEWER
Check what the minimum levels are for the various stationery items (if the minimum levels for stationery has not been determined by the facility, the facility will be non-compliant to this element). Verify that the minimum required are present on the shelves. The facility will not be compliant if the minimum levels are not present. If the facility has already placed an order but the order has not arrived, yet the facility is non-compliant.
CHECKLIST FOR ELEMENT 26
CLINICAL AND ADMINISTRATIVE STATIONERY IS AVAILABLE AT THE HOSPITAL IN SUFFICIENT QUANTITIES
Stationery type
Facility minimum required quantity (Record must be available stipulating the facility’s minimum required quantities)
Goods and supplies order forms/books
Patient folders
Road to Health Booklet for Boys
Road to Health Booklet for Girls
Appointment Cards - General
Patient information registers/Tick sheet
Referral forms
Sick certificate
Discharge summary form
Maternity case records
Partogram
Imaging services request forms
Continuation sheets
Presciption forms
Total score
Maximum possible score
Percentage score %
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NB Element 27: There is a single patient folder irrespective of health
conditions and services accessed
RESP
ONS
IBLE PERSON All patients should have a single folder that contains outpatient and inpatient notes irrespective of the diagnostic conditions. Tuberculosis and ART stationery should be integrated into the single folder.
REVIEWERRandomly select 10 outpatient folders and check that patients’ with co-morbidities have all their clinical records in a single folder.
There is no checklist for this element
Element 28: Patient record is fully completed
RESP
ONS
IBLE PERSON
All administrative details, demographic details must be fully completed on the patient folder. The clinical notes must be legibly completed and preferably using the SOAP format.
Medicines prescribed and frequency of dosage must be noted.
All inpatients notes must be completed updated and must be signed.
Discharge summaries as well as admission/discharge forms must be enclosed in the patient record.
REVIEWERRandomly select 10 outpatient and 10 inpatient records and assess whether the records are completed in full.
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CH
EC
KLI
ST F
OR
ELE
ME
NT
28
PAT
IEN
T R
EC
OR
D IS
FU
LL C
OM
PLE
TE
D
AD
MIN
ISTR
ATI
VE
D
ETA
ILS
(ON
CO
VE
R
OF
RE
CO
RD
)
OPD 1
OPD 2
OPD 3
OPD 4
OPD 5
OPD 6
OPD 7
OPD 8
OPD 9
OPD 10
INPATIENT 1
INPATIENT 2
INPATIENT 3
INPATIENT 4
INPATIENT 5
INPATIENT 6
INPATIENT 7
INPATIENT 8
INPATIENT 9
INPATIENT 10
Nam
e an
d s
urn
ame
Pat
ien
t fi
le n
um
ber
Fac
ility
nam
e
ID/R
efu
gee
/pas
spo
rt n
um
ber
O
R d
ate
of
bir
th
Dem
og
rap
hic
det
ails
Sco
re
Res
iden
tial
ad
dre
ss
P
erso
nal
co
nta
ct d
etai
ls
N
ame
and
su
rnam
e o
f p
aren
ts
or
gu
ard
ian
Co
nta
ct d
etai
ls o
f p
aren
ts o
r g
uar
dia
n
N
ext
of
kin
co
nta
ct d
etai
ls
E
mp
loym
ent
con
tact
det
ails
(i
f em
plo
yed
)
M
arit
al s
tatu
s
P
atie
nt
pro
file
1st
vis
it
Ty
pe
of
emp
loym
ent
So
cial
(ty
pe
of
emp
loym
ent,
liv
ing
co
nd
itio
ns,
so
cial
as
sist
ance
, co
oki
ng
met
ho
d)
So
cial
(sc
ho
ol g
rad
e, s
oci
al
assi
stan
ce, n
utr
itio
n, w
her
e ch
ild li
ves)
Hea
lth
ris
k fa
cto
rs (
alco
ho
l, sm
oki
ng
, oth
er s
ub
stan
ces,
p
hysi
cal a
ctiv
ity,
hea
lthy
ea
tin
g, s
exu
al b
ehav
iou
r)
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CH
EC
KLI
ST F
OR
ELE
ME
NT
28
PAT
IEN
T R
EC
OR
D IS
FU
LL C
OM
PLE
TE
D
AD
MIN
ISTR
ATI
VE
D
ETA
ILS
(ON
CO
VE
R
OF
RE
CO
RD
)
OPD 1
OPD 2
OPD 3
OPD 4
OPD 5
OPD 6
OPD 7
OPD 8
OPD 9
OPD 10
INPATIENT 1
INPATIENT 2
INPATIENT 3
INPATIENT 4
INPATIENT 5
INPATIENT 6
INPATIENT 7
INPATIENT 8
INPATIENT 9
INPATIENT 10
Clin
ical
det
ails
Sco
re
His
tory
of
pre
sen
tin
g
com
pla
in
B
asic
exa
min
atio
n.
Ass
essm
ent
or
dia
gn
osi
s m
ade.
P
lan
– r
elat
ed t
o a
sses
smen
t.
In
vest
igat
ion
s –
pro
ble
m
ori
enta
ted
.
M
edic
ines
ad
min
iste
red
as
pre
scri
bed
(ty
pe
and
fr
equ
ency
)
Pre
scri
ber
’s s
ign
atu
re
V
ital
sig
ns
reco
rded
as
pre
scri
bed
.
Inp
atie
nt r
eco
rds
Ad
mis
sio
n e
ntr
y an
d
asse
ssm
ent
form
co
mp
lete
d.
Pro
gre
ss n
ote
s ev
ery
6 h
ou
rs
on
eac
h p
atie
nt.
Ove
rnig
ht
acco
rdin
g t
o p
atie
nts
co
nd
itio
n
All
entr
ies
are
dat
ed, t
imed
an
d s
ign
ed
P
rog
ress
no
tes
wit
h d
ate
and
ti
me.
A
ll en
trie
s w
ith
sig
nat
ure
A d
isch
arg
e su
mm
ary
rep
ort
is
ava
ilab
le in
ch
art
Ad
mis
sio
n/d
isch
arg
e fo
rm
fille
d in
Tota
l sco
re
Max
imum
po
ssib
le s
core
Per
cent
age
sco
re %
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Element 29: Maternity Case Record is fully completedRE
SPO
NSIBLE PERSON A fully completed maternity record must contain all the administrative, demographic details
of the patient, antenatal records for each visit including relevant investigations, gestational charts, observation charts during labour, partogram and additional clinical notes.
REVIEWERRandomly select 5 maternity case records of patients that have delivered their babies in the last three months and assess if the record is fully completed.
CHECKLIST FOR ELEMENT 29
MATERNITY CASE RECORD IS FULLY COMPLETED
Type of information/notes Score Record 1 Record 2 Record 3 Record 4 Record 5
Administrative details (on cover of record) Name and surname Patient file number Facility name ID/Refugee/passport number OR date of birth Demographic details Residential address Personal contact details Name and surname of parents or guardian (if applicable) Contact details of parents or guardian (if applicable) Next of kin contact details Employment contact details (if employed) Marital status Patient profile Type of employment Social (type of employment, living conditions, social assistance, cooking method) Social(school grade, social assistance, nutrition, where child lives) Health risk factors (alcohol, smoking, other substances, physical activity, healthy eating, sexual behaviour) Family history of chronic conditions/congenital disorders Known chronic conditions Surgical history Allergies
Antenatal record
Planned pregnancy (Yes/No) Booked under 20 weeks (Yes/No) Booked after 20 weeks (Yes/No) LNMP (Last normal menstrual period) EDD (expected date of delivery) Future contraception selected Infant feeding option discussed Risk assessment Clinical management Height of patient
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CHECKLIST FOR ELEMENT 29
MATERNITY CASE RECORD IS FULLY COMPLETED
Type of information/notes Score Record 1 Record 2 Record 3 Record 4 Record 5
Weight Body mass index (BMI) calculated Temperature Blood pressure Pulse rate Blood sugar as per guidelines Urine dipstick as per guidelines Basic screening where indicated (HIV, TB, STI, Diabetes,) Current chronic condition Adherence to medication Reported side effects of medication Other hospital/doctor visits
Examination
General (JACCOL) Chest Cardiovascular Abdomen Vaginal examination Mental state Diagnosis
Patient management Investigations/tests - PAP smear Investigations/tests - Syphilis Investigations/tests - Rhesus Investigations/tests - Hb Investigations/tests - HIV Gestational growth chart completed for each visit Observation chart completed fully (if diagnosis of labour is doubtful) Observation chart for antenatal problem admissions completed fully Initial labour chart completed fully Each assessment section to be fully completed Partogram completed fully Corresponding clinical notes provide full information Health Care Practitioner’s name and surname Health Care Practitioner’s signature Date signed by Health Care Practitioner SANC/HPCSA Number
Total score
Total maximum possible score
Percentage score %
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Component 1: Administration
Sub-component 5: Management of patient appointments
COMMITMENT FOR SUB-COMPONENT 5: Monitor whether a patient appointment system is adhered to.
Administrative/Reception Services and Pharmacy management
ELE
ME
NTS
NB 30 Patients are provided with information on the appointment system
NB 31 Patient appointment management process is adhered to
NB 32 Records of booked patients are pre-retrieved not later than the day before the appointment
33 Pre-dispensed medication for clinically stable chronic patients is prepared for collection not later than the day before collection date/ are registered on the CCMDD programme
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 30: Patients are provided with information on the
appointment system
RESP
ONS
IBLE PERSON Inform patients about the appointment scheduling system at the hospital for chronic stable patients, doctor referrals, follow up appointments and surgical procedures. Provide this at the reception services and all waiting areas.
REVIEWERObserve whether patients are provided with information about the appointment system at the reception areas as well as waiting areas. Ask the administrative clerk as to what information is provided to patients about the appointment system.
There is no checklist for this element
NB Element 31: Patient appointment management process is adhered to
RESP
ONS
IBLE PERSON
Develop a standard operating procedure for the scheduling of appointment. This SOP should detail type of patient that appointment is to be scheduled, process for selecting the date and follow up system if patient misses the appointment.
Use an appointment schedule for stable chronic patients and patient with follow up appointments as well as elective procedures.
Arrive at an appointment date by consensus with the patients.
Follow up patients that have missed scheduled appointments through outreach teams or directly with the patients.
REVIEWER Request to see the documented procedure for scheduling of patients appointments as well as the appointment scheduler in the different service areas. Ask the booking staff as to how patients that miss appointments are followed up. Observe whether the appointment process is adhered to in the areas listed below.
CHECKLIST FOR ELEMENT 31
PATIENT APPOINTMENT MANAGEMENT PROCESS IS ADHERED TO
Description Score Areas Areas Areas
SOP for patient appointment management is available
An appointment scheduler is available
Patient that missed appointments are followed up
Total score
Maximum possible score
Percentage score %
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 32: Records of booked patients are pre-retrieved not later
than the day before the appointmentRE
SPO
NSIBLE PERSON
The appointment scheduler with the name of patients pre-booked for the next day should be handed to the reception/administration services. The patient’s clinical records should be then retrieved and ticked off in the appointment scheduler. The clinical records should then be handed to clinical staff to update prescriptions and laboratory results.
REVIEWERCheck the current appointment scheduler to see if the retrieval of patient records is conducted. Interview the administration/reception staff to explain the process for pre-retrieval of patient records.
There is no checklist for this element
Element 33: Pre-dispensed medication for clinically stable chronic patients is prepared for collection not later than the day before collection date/ are registered on the CCMDD programme
RESP
ONS
IBLE PERSON
All stable patients that qualify for the CCMD programme should be enrolled using the Standard Operating Procedures. Patient that are stable and can be managed at a lower level of care should be down referred. More specifically at district hospitals- if patients are attending are attending for medication collection then medication should be pre-dispensed.
Pre-dispense means the interpretation and evaluation of the prescription and the preparation and labelling of the prescribed medicine (Phases 1 and 2 of dispensing as defined in the Pharmacy Act, 1974 (Act 53 of 1974)).
REVIEWER
Check whether stable chronic patients are down referred or registered for CCMD programme. For those stable chronic patients returning for medication collection check that pre-dispensed medication for clinically stable chronic patients is prepared for collection not later than the day before collection date.
There is no checklist for this element
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Component 2: Clinical Organisation
Sub-component 6: Clinical services
COMMITMENT FOR SUB-COMPONENT 6: Monitor whether the services offered are aligned to the hospital package of Services
Hospital Corporate Services Executive Management, specifically the Clinical Manager
ELE
ME
NTS
34 Defined package of service for level of hospital care is available
35 Hospital offers Emergency Health Services (24 hours) 36 Hospital offers Ambulatory services (minimum 8 hours, 5 days a week)
37 Hospital offers In-Patient services
38 Hospital offers health support services
39 Hospital offers a dedicated isolation facility for patients with infectious diseases
40 Hospital offers a dedicated isolation facility for patients admitted under the Mental Health Care Act
NB 41 Hospital Ambulatory service areas are organised with designated consulting areas
42 Operating theatre service is organised into functional areas for efficient work flow
NB 43 Patients are consulted, examined and counselled in privacy
NB 44 Schedule of outreach services from higher levels of care available
NB 45 Clinical medico-legal services provided
NB 46 Access to forensic medico-legal services is available
NB 47 Schedule for DCST visits to the hospital to provide clinical support and mentoring is adhered to
Vital Essential NB Important
Who is responsible for this sub-component?
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Elements 34: Defined package of service for level of hospital care is available
RESP
ONS
IBLE PERSON
Obtain a copy of the approved package of services that should be offered based on the level of care from www.doh.gov.za. All services listed within the defined package of care for that specific level of care should be provided. Specifically the hospital must provide a 24 hour emergency service for acute care and obstetric cases. Ambulatory services should be provided for a minimum of eight hours on five days of the week. Inpatient services and health support service should be provided on site.
REVIEWERCheck that the hospital has an approved package of services based on the level of care.
CHECKLIST FOR ELEMENT 34
DEFINED PACKAGE OF SERVICE FOR LEVEL OF HOSPITAL CARE IS AVAILABLE
Description Score
District hopital
Regional hospital
Tertiary hospital
Central hospital
Specialised
Total score
Maximum possible score
Percentage score %
Elements 35: Hospital offers Emergency Health Services (24 hours)
RESP
ONS
IBLE PERSON
Obtain a copy of the approved package of services that should be offered based on the level of care from www.doh.gov.za. All services listed within the defined package of care for that specific level of care should be provided. Specifically the hospital must provide a 24 hour emergency service for acute care and obstetric cases. Ambulatory services should be provided for a minimum of eight hours on five days of the week. Inpatient services and health support service should be provided on site.
REVIEWERVerify that the emergency health services (Accident and Emergency Unit, and Obstetrics Unit) are available over 24 hours a day, seven days a week according to the defined package of service.
There is no checklist for this element
Accident & emergency unit Obstetrics unit
CHECK IN THESE
FUNCTIONAL AREAS
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Elements 36: Hospital offers ambulatory services (minimum 8 hours, 5 days a week)
RESP
ONS
IBLE PERSON
Obtain a copy of the approved package of services that should be offered based on the level of care from www.doh.gov.za. All services listed within the defined package of care for that specific level of care should be provided. Specifically the hospital must provide a 24 hour emergency service for acute care and obstetric cases. Ambulatory services should be provided for a minimum of eight hours on five days of the week. Inpatient services and health support service should be provided on site.
REVIEWERVerify that Ambulatory services are provided on an out-patient basis for a minimum of 8 hours and include acute non-emergency services, chronic services and obstetric services. The services must be offered for Adults, Adolescent and Paediatrics.
There is no checklist for this element
Elements 37: Hospital offers in-patient services
RESP
ONS
IBLE PERSON
Obtain a copy of the approved package of services that should be offered based on the level of care from www.doh.gov.za. All services listed within the defined package of care for that specific level of care should be provided. Specifically the hospital must provide a 24 hour emergency service for acute care and obstetric cases. Ambulatory services should be provided for a minimum of eight hours on five days of the week. Inpatient services and health support service should be provided on site.
REVIEWER
Verify that the hospital provides in-patient admissions for hospitalised care for all common medical, paediatric, surgical and obstetric and disability related conditions and procedures and has a fully functional theatre.
Intensive care and high care units should be available at Regional, Tertiary and Central Hospitals.
There is no checklist for this element
Elements 38: Hospital offers health support services
RESP
ONS
IBLE PERSON
Obtain a copy of the approved package of services that should be offered based on the level of care from www.doh.gov.za. All services listed within the defined package of care for that specific level of care should be provided. Specifically the hospital must provide a 24 hour emergency service for acute care and obstetric cases. Ambulatory services should be provided for a minimum of eight hours on five days of the week. Inpatient services and health support service should be provided on site.
REVIEWER Verify that the hospital provides the following health support services on an outpatient and inpatient services.
There is no checklist for this element
Obstetrics unitAmbulatory health services (acute, chronic, obstetric)
CHECK IN THESE
FUNCTIONAL AREAS
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive care/high Care
Theatre
CHECK IN THESE
FUNCTIONAL AREAS
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Radiology
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
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Element 39: Hospital offers a dedicated isolation facility for patients with infectious diseases
RESP
ONS
IBLE PERSON The hospital should have a designated ward or room that can be easily set up to function as an isolation facility for patients with suspected infectious diseases, for prevention of transmission of infection to other patients.
REVIEWERCheck whether the hospital has an isolation room/ward. If the hospital does not have one, check if there is an identified ward/room that can be used for this purpose.
There is no checklist for this element
Element 40: Hospital offers a mental health inpatient unit for patients admitted under the Mental Health Care Act
RESP
ONS
IBLE PERSON The hospital must have a designated isolation facility for patients requiring mental health services or observation. This isolation facility must meet the requirements of the Mental Health Care Act, and must be free from items that could be used by the patient to inflict harm on him/herself or others.
REVIEWER
Assess if the isolation facility is in accordance with legislation requirements.
CHECKLIST FOR ELEMENT 40
HOSPITAL OFFERS A MENTAL HEALTH INPATIENT UNIT FOR PATIENTS ADMITTED UNDER THE MENTAL HEALTH CARE ACT
Description Score
The hospital has a mental health unit to provide for admissions of voluntary , assisted , emergency mental health care patients/users, 72-hour assessment of involuntary mental health care users.
The mental health care unit is self-contained and provides a safe and secure therapeutic environment.
Seclusions are placed/located next to nurses’ station
The design must avoid any item or furniture that are vandal prone, can be used as weapons and or self harm
All fittings must be tamperproof
The layout and design must prevent areas of concealment for purposes of hiding or launching surprise attacks on others or staff.
Consistent with the mental health care users’ safety, corridors and shared spaces must be monitored with Closed Circuit Television (CCTV).
Panic buttons should be installed in each room to summon additional staff and help from elsewhere in the facility
The windows and doors to the rooms must prevent escape, unwarranted entrance or opportunities for self-harm.
Doors of the rooms must be solid core, reinforced and must lock from outside.
Safe and secured treatment rooms must be available for medical procedures and clinical care.
Patient accommodation should be shielded from public activities and should provide privacy and personal space.
Main entrance to the unit/ward must be security controlled
Total score
Maximum possible score
Percentage score %
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NB Element 41: Hospital Ambulatory service areas are organised with
designated consulting areas
RESP
ONS
IBLE PERSON Map out all the ambulatory services offered at the facility. Determine the utilisation of these services. Match the services with the available consulting room such that the service shave designated consulting rooms and waiting areas.
REVIEWER Observe whether consulting rooms have been allocated to each ambulatory service based on utilisation.
There is no checklist for this element
Element 42: Operating theatre service is organised into functional areas for efficient work flow
RESP
ONS
IBLE PERSON The operating theatre should be designed with specific functional areas to minimise the risk of infection for patients and healthcare workers. The design should support efficient workflow. There must be separate areas or rooms for the clean and dirty supplies. There should be a recovery room as well as a waiting area.
REVIEWER Conduct a walk through the operating theatre and assess whether the operating theatre has an external waiting area, staff rooms, storage area, patient holding areas, recovery room, theatre scrub areas and waste holding area.
CHECKLIST FOR ELEMENT 42
OPERATING THEATRE SERVICE IS ORGANISED INTO FUNCTIONAL AREAS FOR EFFICIENT WORK FLOW
Description Score
External waiting area
Staff change rooms
Storage area (linen, surgical stores)
Patient holding area
Recovery areas
Theatre scrub area
Waste area (dirty area)
Total score
Maximum possible score
Percentage score %
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NB Element 43: Patients are consulted, examined and counselled in
privacy RE
SPO
NSIBLE PERSON
All healthcare workers must consult, examine and/or counsel patients in a manner in an environment (behind closed doors/curtains/ screens) that protects their privacy.
REVIEWER Observe whether patients are being consulted, examined or counselled in privacy in the areas listed below:
There is no checklist for this element
NB Element 44: Schedule of outreach services from higher levels of care
available
RESP
ONS
IBLE PERSON All hospital must have a schedule of the outreach services it receives and/or provides (depending on the level of care). At a district hospital this will be for doctors visiting feeder clinics, whilst at regional and tertiary hospitals this will be for specialist conducting specialist clinics at district hospitals.
REVIEWERCheck that there is a schedule of outreach services from higher levels of care or to lower level of care.
CHECKLIST FOR ELEMENT 44
SCHEDULE OF OUTREACH SERVICES FROM HIGHER LEVELS OF CARE AVAILABLE
Description Score
Medicine
Surgery
Obstetrics
Opthalmology
Paediatrics
Psychaitry
ENT
Orthopaedics
Total score
Total maximum possible score
Percentage score %
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and palliative care
Radiology
Pharmacy
Executive management
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 45: Clinical medico-legal services provided
RESP
ONS
IBLE PERSON Hospital must be able to provide clinical-medical legal services such as assessment of patients with trauma and completion of J88 forms, assessing patients with sexual assault and conducting mental observations as directed by a judge.
REVIEWER Interview the clinical service providers and request them to explain the process for medical legal services.
There is no checklist for this element
NB Element 46: Access to forensic medico-legal services is available
RESP
ONS
IBLE PERSON
Non-natural deaths require autopsies at the state mortuaries. The hospital must have the contact numbers of the district surgeons as well as the relevant state mortuary.
REVIEWER Check that the numbers of the district surgeon as well as number for the state mortuaries are available in Emergency Department of Hospital.
There is no checklist for this element
NB Element 47: Schedule for DCST visits to the hospital to provide
clinical support and mentoring is adhered to
RESP
ONS
IBLE PERSON This element is only applicable to District Hospitals. The District Clinical Specialist Team (DCST) should provide clinical support and mentoring to staff at district hospitals. The hospital must have a schedule of the DCST visits to the hospital.
REVIEWER Check that there is a schedule of DCST visits.
There is no checklist for this element
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Who is responsible for this sub-component?
Component 2: Clinical Organisation
Sub-component 7: Referrals
COMMITMENT FOR SUB-COMPONENT 7: Monitor whether the Referral guidelines and policy are adhered to
Hospital Corporate Services – Executive Management and more specifically the Clinical Manager.
ELE
ME
NTS
NB 48 National Referral Policy and Guideline is available
NB 49 Hospital has defined referral pathways
NB 50 There is a register that records patient referrals
51 Protocol available for the handover to/from EMS
52 There is a standard operating procedure for hospital closure and ambulance diversion
Vital Essential NB Important
NB Element 48: National Referral Policy and Guideline is available
RESP
ONS
IBLE PERSON
The facility must have a copy of the National Referral Policy and Guideline (available from www.health.gov.za)
REVIEWERVerify that the hospital has a copy of the National Referral Policy and Guidelines.
There is no checklist for this element
NB Element 49: Hospital has defined referral pathways
RESP
ONS
IBLE PERSON The hospital must map the referral pathway (both up-referral and down-referral) for all clinical and health support services. These referral pathways must be in line with the National Referral Policy and Guidelines. Each clinical and health support service are must have a copy of the referral pathway for their service.
REVIEWER
Request to see the referral pathways for the different services at the hospital. Check that each clinical and health support service area has a copy of the referral pathway.
There is no checklist for this element
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NB Element 50: There is a register that records patient referrals
RESP
ONS
IBLE PERSON
Each clinical and health support service area (including wards) must keep a register that records referral into or out of the hospital.
REVIEWER
Check that each clinical and health support service area has a register of patient referrals.
There is no checklist for this element
Element 51: Protocol available for the handover to/from EMS
RESP
ONS
IBLE PERSON The hospital must have a protocol that details the process for patient handover to or from EMS. This must indicate all the documents to be completed and the information to be provided.
REVIEWER
Request to see a copy of the protocol for patient handover to/from EMS. Interview the staff and ask them to explain the process for patient handover to/from EMS.
There is no checklist for this element
Element 52: There is a standard operating procedure for hospital closure and ambulance diversion
RESP
ONS
IBLE PERSON
The hospital must have an SOP that details that process to follow in the event of the capacity of the hospital is exceeded and the hospital needs to be closed. This SOP must include the diversion of emergency services, where admitted patients will be transferred to if necessary, and where patients can seek outpatient services.
REVIEWER
Request to see a copy of the protocol for hospital closure and ambulance diversion. Interview the clinical manager/CEO and ask them to explain the process for hospital closure and ambulance diversion.
There is no checklist for this element
Accident & emergency unit
Obstetrics unit
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive care/high Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and palliative care
CHECK IN THESE
FUNCTIONAL AREAS
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Component 3: Clinical Governance
Sub-component 8: Clinical guidelines and protocols
COMMITMENT FOR SUB-COMPONENT 8: Monitor whether clinical guidelines and protocols are available, and appropriately used.
The responsibility for this sub-component lies with the Hospital Corporate Services- Executive Management and more specifically the Clinical Manager.
ELE
ME
NTS
53 Clinical guidelines for the defined hospital package of services is available in designated areas
NB 54 Resuscitation protocols are available
NB 55 South African Triage Scale is available
56 Protocol to identify deterioration in in-patients is available
57 National guidelines are followed for all notifiable medical conditions
58 SOP for the safe administration of medicines is adhered to
59 SOP for the management and use of blood and blood products is adhered to
60 The emergency trolley is restored daily or after each use
61 SOP for refusal of treatment available
62 SOP for handover between shifts is available
63 SOP for outbreak notification and response are available
64 SOP for management of elderly, frail or patients with reduced mobility is adhered to
Vital Essential NB Important
Who is responsible for this sub-component?
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Element 53: Clinical guidelines for the defined hospital package of services is available in designated areas
RESP
ONS
IBLE PERSON
A hard copy or electronic copy of clinical guidelines for or the Standard treatment guidelines, Priority conditions and Infection Prevention and Control based on the defined hospital package of services must be available in the emergency health services area, inpatient areas (except high care, intensive care and theatre), and in the outpatient departments.
REVIEWER Request to see either hard copies or electronic copies of the clinical guidelines for the Standard treatment guidelines, Priority conditions and Infection Prevention and Control. These should be available in all clinical service areas.
CHECKLIST FOR ELEMENT 53
CLINICAL GUIDELINES FOR THE DEFINED HOSPITAL PACKAGE OF SERVICES IS AVAILABLE IN DESIGNATED AREAS (ELECTRONICALLY OR HARD COPY)
Description Score
Standard Treatment Guidelines
Priority conditions
Infection prevention and control
Total score
Total maximum possible score
Percentage score %
NB Element 54: Resuscitation protocols are available
RESP
ONS
IBLE PERSON A resuscitation protocol for both adult and paediatric patients must be available in the emergency services areas and all clinical service areas (including wards). The resuscitation protocol must include the process to follow as well as responsibility of each service provider.
REVIEWERVerify that all clinical service areas (including wards) have a resuscitation protocol.
There is no checklist for this element
Accident & emergency unit
Obstetrics unit
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Ambulatory health services (acute, chronic, obstetric)
Oral health services
CHECK IN THESE
FUNCTIONAL AREAS
Accident & emergency
Obstetrics
Paediatric Ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive care/high Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Oral health services
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 55: South African Triage Scale is available
RESP
ONS
IBLE PERSON
The hospital must have a copy of the South African Triage Scale available in the emergency and ambulatory clinical areas. The South African Triage Scale (SATS), is a physiology and symptom based scale which prioritises into one of four colours and can be used in hospital Emergency Centres as well as in the pre-hospital setting. Download the South African Triage Scale from https://emssa.org.za/wp-content/uploads/2011/04/SATS-Manual-A5-LR-spreads.pdf
REVIEWER
Observe to see if the triage scale is available in all clinical service areas.
Accident & emergency Obstetrics
Ambulatory health services (acute, chronic, obstetric)
Oral health services
CHECK IN THESE
FUNCTIONAL AREAS
There is no checklist for this element
Element 56: Protocol to identify deterioration in in-patients is available
RESP
ONS
IBLE PERSON The hospital must have an SOP for the monitoring of inpatients. The SOP must include a list of signs to identify an inpatient whose clinical condition is deteriorating and warrants further investigation and management.
REVIEWERRequest to see a copy of the protocol for identifying inpatients.
There is no checklist for this element
Priority colour Target time Management
Red IMMEDIATE Take to the resuscitation room for emergency management
Orange < 10 mins Refer to majors for very urgent management
Yellow < 1 hour Refer to majors for urgent management
Green < 4 hours Refer to designated area for non-urgent cases
Blue < 2 hours Refer to doctor for certification
Paediatric ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
CHECK IN THESE
FUNCTIONAL AREAS
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Element 57: National guidelines are followed for all notifiable medical conditions
RESP
ONS
IBLE PERSON
The hospital must have an electronic or hard copy of the National guidelines for notifiable medical conditions that includes the flowchart of the notification process, case definitions and case investigation and notification forms. The hospital must report NMCs using the web-based application or using the paper-based system.
REVIEWERCheck that the National Guidelines for notifiable medical conditions are available. Review the notification forms (from the last 6 months) if available as hard copies. Ask a staff member to explain the notification process (both paper and web-based).
There is no checklist for this element
Element 58: SOP for the safe administration of medicines is adhered to
RESP
ONS
IBLE PERSON The hospital must have an SOP for the safe administration of medicines. The protocol detail the procedures for checking the correct dose, route, timing, frequency and the correct patient receiving the medication.
REVIEWER Randomly select ten inpatient records and review the prescription/medicines chart to see that the correct dose, timing, route and frequency of medicines were administered to the correct patient.
CHECKLIST FOR ELEMENT 58
SOP FOR THE SAFE ADMINISTRATION OF MEDICINES IS ADHERED TO
Description Score
Correct medicine is administered to correct patients
Correct dose of medicine is administered
Correct route of administration
Correct time of administration
Correct frequency of administration
Total score
Total maximum possible score
Percentage score %
CHECK IN THESE
FUNCTIONAL AREAS
Accident & emergency
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Ambulatory health services (acute, chronic, obstetric)
Oral health services
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Element 59: SOP for the management and use of blood and blood products is adhered to
RESP
ONS
IBLE PERSON The hospital must have an SOP for the safe management and use of blood and blood products. The protocol must detail the temperature for storing of blood, transporting blood to the ward, identification of the patient, administration of blood, monitoring of patient during administration of blood and the standard precautions to be adopted.
REVIEWER Verify that there is a SOP for the safe management and use of blood and blood products. Observe a patient receiving a blood or blood product or Interview a staff member in each ward and ask for an explanation of the safe management and use of blood and blood products. This should be checked in the following areas listed ibelow:
CHECKLIST FOR ELEMENT 59
SOP FOR THE MANAGEMENT AND USE OF BLOOD AND BLOOD PRODUCTS IS ADHERED TO
Description Score
Blood/blood product is stored at correct temperature
Blood/blood product is transported to the ward maintaining cold chain
Correct patient is identified
Correct blood/blood product is administered
Accurate documentation with patient details and details of blood/blood product to be administered
Blood/blood product is administered at correct temperature
Patients’ vital signs are monitored before, during and after the administration of the blood/blood product
Standard precautions practiced by healthcare worker administering the blood/blood product
Total score
Total maximum possible score
Percentage score %
Element 60: The emergency trolley is restored daily or after each use
RESP
ONS
IBLE PERSON The hospital must have a list of specifications for equipment and supplies needed for the emergency trolley. There must be a schedule to determine who is responsible for restoring the emergency trolley daily and after each use on the specific day.
REVIEWERVerify that the emergency trolley has been checked and restored at the beginning of every shift and after every use by reviewing the inventory list that has been signed off. Conduct a spot check to determine if the emergency trolley is restored.
There is no checklist for this element
Accident & emergency
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive care/high Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Oral health services
CHECK IN THESE
FUNCTIONAL AREAS
Accident & emergency unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Oral health services
CHECK IN THESE
FUNCTIONAL AREAS
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Element 61: SOP for refusal of treatment availableRE
SPO
NSIBLE PERSON A patient may refuse treatment and such refusal can be verbal or in writing. The
hospital must have an SOP for the management of patients refusing treatment that includes counselling of patient and the relevant forms to be signed by patients.
REVIEWERVerify that the hospital has a SOP for refusal of treatment. Ask a staff member to explain the process to follow when a patient refuses treatment.
There is no checklist for this element
Element 62: SOP for handover between shifts is available
RESP
ONS
IBLE PERSON
Patient care must be continuous. At the end of each shift, healthcare providers must handover each patient to the subsequent healthcare provider. Information regarding the patients mental state, vital signs, special requests by the doctor, any investigations outstanding or that are to be conducted, as well as any procedures that the patient may be booked for as well as if the patient will be nil per os.
REVIEWERVerify that the hospital has a SOP on the handover of patients between shifts. Ask a staff member to explain the process to follow when handing over between shifts.
There is no checklist for this element
Accident & emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
Accident & emergency unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Outpatient (Acute/Chronic/Obstetric)
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Element 63: SOP for outbreak notification and response is availableRE
SPO
NSIBLE PERSON The hospital should have a hard or electronic copy of the National Guidelines on
Epidemic Preparedness and Response (available from www.health.gov.za). The hospital must have an SOP for outbreak notification and response that is aligned to the national guidelines.
REVIEWERCheck for that the hospital has a copy of the National Guidelines and has an SOP for outbreak notification and response.
There is no checklist for this element
Element 64: SOP for management of elderly, frail or patients with reduced mobility is adhered to
RESP
ONS
IBLE PERSON
Ensure that the hospital has a SOP for the management of elderly, frail or patients with reduced mobility and assisted devices. This protocol will include process for identifying patients who are considered frail Elderly (patients over the age of 75 and who have medical problems relating to the ageing process, for example reduced mobility and/or incontinence) when they arrive at the hospital; coordination of patient care using a multidisciplinary team based approach and planning the patients discharge as well as home based care.
REVIEWER Request to see a copy of the protocol or SOP for management of the elderly, frail or patients with reduced mobility. Interview the staff and ask about the process followed for management of the elderly, frail or patients with reduced mobility.
There is no checklist for this element
Accident & emergency unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive care/high Care
Theatre
Outpatient (Acute/Chronic/Obstetric)
CHECK IN THESE
FUNCTIONAL AREAS
Accident & emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
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Component 3: Clinical Governance
Sub-component 9: Clinical audits
COMMITMENT FOR SUB-COMPONENT 9: Monitor clinical performance against defined standards of care.
Hospital Corporate Services – Executive Management and more specifically the Clinical Manager
ELE
ME
NTS
65 National Clinical Audit Guideline is available
66 Clinical audits are conducted quarterly
67 80% of all assessed patient records fulfil the defined criteria for each condition
68 Clinical audit meetings are held quarterly
69 Drug utilisation reviews conducted quarterly
70 Morbidity and mortality reviews are conducted monthly
Vital Essential NB Important
Element 65: National Clinical Audit Guideline is available
RESP
ONS
IBLE PERSON
Ensure that the hospital has a hard or electronic copy of the National Clinical Audit Guidelines (available from www.health.gov.za).
REVIEWER Request to see a copy of the National Clinical Audit Guidelines.
There is no checklist for this element
Who is responsible for this sub-component?
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Element 66: Clinical audits are conducted quarterlyRE
SPO
NSIBLE PERSON
Clinical audits should be conducted quarterly in line with the National guidelines on priority conditions and in each clinical and health support service discipline.
REVIEWER Obtain reports of the clinical audits conducted for the past 12 months. Verify that all relevant conditions and disciplines (Checklist 66) are being audited. The reports should indicate plans to improve patient management.
CHECKLIST FOR ELEMENT 66
CLINICAL AUDITS ARE CONDUCTED QUARTERLY ON PRIORITY HEALTH CONDITIONS
Description Score
HIV
Tuberculosis
Non communicable diseases- Hypertension
Non communicable diseases- Diabetes
Maternal health (ANC &PNC)
Well baby
Sick child (IMCI)
Total score
Maximum possible score
Percentage score %
Element 67: 80% of all assessed patient records fulfil the defined criteria for each condition
RESP
ONS
IBLE PERSON
The results of the clinical audit should indicate that at least 80% of assessed patient records are compliant with the defined criteria as per the national guidelines.
REVIEWER Obtain reports from the last 2 clinical audits for the HIV, TB, Hypertension, Diabetes, Antenatal and Post Natal care, well baby and sick child (Checklist 67) to assess if this target is being met.
CHECKLIST FOR ELEMENT 67
80% OF ALL ASSESSED PATIENT RECORDS FULFIL THE DEFINED CRITERIA FOR EACH PRIORITY CONDITION
Description Score
HIV
Tuberculosis
Non communicable diseases- Hypertension
Non communicable diseases- Diabetes
Maternal health (ANC &PNC)
Well baby
Sick child (IMCI)
Total score
Maximum possible score
Percentage score %
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Element 68: Clinical audit meetings are held quarterly
RESP
ONS
IBLE PERSON The hospital must conduct clinical audit meetings quarterly. These meetings can be discipline specific or combined.
REVIEWERobtain registers and minutes of the clinical audit meetings held in the previous 12 months.
There is no checklist for this element
Element 69 : Drug utilisation reviews conducted quarterly
RESP
ONS
IBLE PERSON The hospital must conduct drug utilisation reviews quarterly. A multidisciplinary and include pharmacists, doctors, nurses, microbiologists (if available) and clinical management must be established for this purpose.
REVIEWERObtain registers and minutes of the drug utilisation review meetings held in the previous 12 months.
There is no checklist for this element
Element 70: Morbidity and mortality reviews are conducted monthly
RESP
ONS
IBLE PERSON
The hospital must conduct monthly morbidity and mortality reviews. These reviews can be discipline specific of combined.
REVIEWERObtain register and minutes of the morbidity and mortality meetings from the previous 6 months.
There is no checklist for this element
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Component 3: Clinical Governance
Sub-component 10: Clinical effectiveness
COMMITMENT FOR SUB-COMPONENT 10: Monitor the outcome of evidence informed clinical practice to achieve optimum processes and outcomes of care for patients
The responsibility for this sub-component lies with the Hospital Corporate Services- Executive Management and more specifically the Clinical Manager.
ELE
ME
NTS
NB 71 National target for control of communicable diseases is achieved
NB 72 National target for control of non-communicable diseases is achieved
NB 73 National target for maternal, child and women’s health is achieved
NB 74 The average length of stay is aligned to national average based on level of care
NB 75 The average waiting time for elective procedures is monitored
NB 76 Bed utilization rate is equal to or above national target for level of care
Vital Essential NB Important
Who is responsible for this sub-component?
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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NB Element 71: National target for control of communicable diseases is
achieved
RESP
ONS
IBLE PERSON The hospital should have a hard or electronic copy of the national targets for the control of tuberculosis, HIV and malaria. Extract the indicators as per the National Dataset from the Facility information system, Tier.net; ETR.net and/or the District Health Information system Results obtained should be in line with National targets.
REVIEWER Request to see the indicators calculated and submitted for the past 12 months for Tuberculosis, HIV and malaria. Assess to see whether the indicators are in line with National targets
CHECKLIST FOR ELEMENT 71
NATIONAL TARGET FOR CONTROL OF COMMUNICABLE DISEASES IS ACHIEVED
Description Score
Tuberculosis
HIV
Malaria
Total
Maximum possible score
Percentage score %
NB Element 72: National target for control of non-communicable
diseases is achieved
RESP
ONS
IBLE PERSON
The hospital should have a hard or electronic copy of the national targets for the control of priority non-communicable diseases such as Hypertension, Diabetes, Cancer and Blindness. Extract the indicators as per the National Dataset from the Facility information system, and/or the District Health Information system Results obtained should be in line with National targets.
REVIEWER Request to see the indicators calculated and submitted for the past 12 months for Hypertension, Diabetes, Cancer and Blindness. Assess to see whether the indicators are in line with National targets.
CHECKLIST FOR ELEMENT 72
NATIONAL TARGET FOR CONTROL OF NON-COMMUNICABLE DISEASES IS ACHIEVED
Description Score
HPT
Diabetes
Cancer
Blindness
Total score
Maximum possible score
Percentage score %
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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NB Element 73: National target for maternal, child and women’s health is
achievedRE
SPO
NSIBLE PERSON
The hospital should have a hard or electronic copy of the national targets for deworming, caesarean section rate, still birth rate and maternal mortality ratio. Extract the indicators as per the National Dataset from the Facility information system, and/or the District Health Information system Results obtained should be in line with National targets.
REVIEWER Request to see the indicators calculated and submitted for the past 12 months for deworming, caesarean section rate, still birth rate and maternal mortality ratio. Assess to see whether the indicators are in line with National targets.
CHECKLIST FOR ELEMENT 73
NATIONAL TARGET/AVERAGE FOR MATERNAL, CHILD AND WOMEN’S HEALTH IS ACHIEVED
Description Score
Deworming
Caeserrian Section Rate
Still birth rate in facility
Maternal mortality ratio
Total score
Maximum possible score
Percentage score %
NB Element 74: The average length of stay is aligned to national average
based on level of care
RESP
ONS
IBLE PERSON
Calculate the average length of stay at the hospital should be calculated (per discipline if possible).
Average length of stay = Total number of occupied hospital bed-days
Total number of discharges
Occupied bed days is calculated as the total Length of stay (LOS) of all patients based on date of discharge - date of admission. If these are the same dates, then LOS is set to one day. ALOS (Average length of stay) should preferably be provided to the
accuracy of hundreds, i.e. 0.01. The hospital should be aware of the national average length of stay for the level of the hospital.
REVIEWER Check that hospital average length of stay has been calculated. If higher than national average, then check that a quality improvement plan has been developed.
There is no checklist for this element
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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NB Element 75: The average waiting time for elective procedures is
monitored
RESP
ONS
IBLE PERSON The hospital management should set targets for the waiting time for specific elective procedures. The hospital should then monitor the waiting time for these specified elective procedures and develop action plans if the waiting times exceeds the target.
REVIEWERCheck for documentation that the hospital is monitoring the waiting times for specific elective procedures and that action plans are drawn up if the waiting time is above the target set by the hospital.
There is no checklist for this element
NB Element 76: Bed utilization rate is equal to or above national target
for level of care
RESP
ONS
IBLE PERSON
The bed utilisation rate refer to the percentage of beds or units that are occupied on a given night or on an average night over a period of time.
To calculate the overall bed utilization rate on a given night, take the number of people served on that night and divide it by the number of beds available on that night.
The average daily utilization rate is calculated by taking the average number of people served over a given time period (e.g., the 12-month reporting period) divided by the total number of beds.
The hospital should be aware of the national target for bed utilisation for the level of the hospital.
REVIEWER Check for documentation that the hospital is monitoring the bed utilisation rate.
There is no checklist for this element
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Who is responsible for this sub-component?
Component 3: Clinical Governance
Sub-component 11: Clinical risk management
COMMITMENT FOR SUB-COMPONENT 11: Monitor the management of risks associated with clinical care
Hospital Corporate Services – Executive Management and more specifically the Clinical Manager.
ELE
ME
NTS
NB 77 Clinical Governance structures are functional
78 Quality improvement plans are implemented
79 National Guideline for Patient Safety Incident Reporting and Learning is available
80 Patient safety incident records comply with the National Guideline for Patient Safety Incident Reporting and Learning
NB 81 An annual risk assessment for infection prevention and control compliance is conducted
NB 82 Surveillance system for healthcare associated infections is implemented
NB 83 Inpatient stay exceeding 10 days is investigated
Vital Essential NB Important
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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NB Element 77: Clinical Governance structures are functional
RESP
ONS
IBLE PERSON The hospital must have a clinical governance committee, and sub-committees are fully constituted; meet at least quarterly and develop and implement action plans to address issues relating to clinical effectiveness. This committee should receive inputs from the various sub-committees and make the necessary decisions.
REVIEWER Obtain registers and minutes of meetings of the clinical governance committee for the past twelve months. Review whether the sub-committee reports are included in all minutes of meetings.
CHECKLIST FOR ELEMENT 77
SOP FOR CLINICAL GOVERNANCE IS ADHERED TO
Description Score
There are terms of reference for the clinical governance committee
There are terms of reference for each sub-committees
Pharmaceutical and therapeutics
Maternal morbidity and mortality
Infection prevention and control
Clinical risk
Multidisciplinary meetings occur as per schedule
Total score
Maximum possible score
Percentage score %
Element 78: Quality improvement plans for clinical services are implemented
RESP
ONS
IBLE PERSON The hospital should have a hard or electronic copy of the National Quality Improvement Guideline (available from www.health.gov.za). Quality improvement plans must be developed according to deficiencies identified in clinical effectiveness and governance.
REVIEWER request documentation pertaining to all quality improvement initiatives. These reports should contain a baseline analysis, identification of deficiencies, root cause analysis, implementation of intervention and evaluation of the intervention.
Accident & emergency unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral health services
Speech therapy
Social work
Eye health
Audiology
Medical orthotics and prosthetics
Radiology
Pharmacy
Laboratory
Mental health
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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CHECKLIST FOR ELEMENT 78
QUALITY IMPROVEMENT PLANS FOR CLINICAL SERVICES ARE IMPLEMENTED
Description Score
There is a designated individual responsible for co-ordination of quality improvement plans
Clinical services
Clinical audit
Patient complaints
Patient Waiting times
Patient safety incidents
Patient experience of care
Referrals
Waiting times for elective procedures
Infection Control
Occupational health & safety
Healthcare risk waste management’
Total score
Maximum possible score
Percentage score %
Element 79: National Guideline for Patient Safety Incident Reporting and Learning is available
RESP
ONS
IBLE PERSONThe hospital must have a hard or electronic copy of the National Guideline for Patient Safety Incident Reporting and Learning (available from www.health.gov.za).
REVIEWERVerify that the hospital has a copy of the National Guideline for Patient Safety Incident Reporting and Learning.
There is no checklist for this element
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 80: Patient safety incident records comply with the National Guideline for Patient Safety Incident Reporting and Learning
RESP
ONS
IBLE PERSON Document all incidents involving patient safety using a standardised template as per the National guideline. Record all incidents in the patient safety incident register. Analyse the patient safety incidents based on type, root causes and outcomes. All service areas should be included.
REVIEWERVerify that patient safety incident reports comply with the National guideline.Checklist 80
CHECKLIST FOR ELEMENT 80
PATIENT SAFETY INCIDENT RECORDS COMPLY WITH THE NATIONAL GUIDELINE FOR PATIENT SAFETY INCIDENT REPORTING AND LEARNING
Description Score
The facility/district Standard Operating Procedure for Patient Safety Incident Reporting and Learning is available
Patient Safety Incident Register
Statistical data on classifications of agents involved
Statistical data on classifications of incident type
Statistical data on classifications of incident outcome
Indicators for patient safety incidents
The register must include reports of incidents from all service areas
Total score
Maximum possible score
Percentage score %
NB Element 81: An annual risk assessment for infection prevention and
control compliance is conducted
RESP
ONS
IBLE PERSON
A comprehensive infection prevention and control risk assessment must be conducted across all clinical and non-clinical service areas annually. This risk assessment must be conducted by a multidisciplinary team including the infection control manager, the quality assurance manager, the monitoring and evaluation manager, systems and maintenance, occupational health, health and safety officer, waste management officer, pharmacist and a clinical representative. All possible infection risks must be identified and plans put in place to mitigate these risks.
REVIEWER
request documentation pertaining to the previous infection prevention and control risk assessment. These reports should contain a baseline analysis, identification of infection risks, root cause analysis, and plan for implementation of interventions to mitigate the risks identified.
There is no checklist for this element
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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NB Element 82: Surveillance system for healthcare associated infections
is implementedRE
SPO
NSIBLE PERSON
The hospital should have a surveillance system in place for the identification and monitoring of healthcare-associated infections in patients. The following infections should be monitored (depending on the level of the hospital): surgical site infections, catheter-associated urinary tract infections, central line-associated bloodstream infection, peripheral line-associated infection, hospital-acquired pneumonia, ventilator-associated pneumonia. The surveillance must include a standardised form to collect data including date the patient had a device inserted and removed, microbiological results, and temperature of the patient.
REVIEWER
Check that the hospital has a surveillance system for the monitoring of healthcare-associated infections.
There is no checklist for this element
NB Element 83: Inpatient stay exceeding 10 days is investigated
RESP
ONS
IBLE PERSON
Inpatient stay that exceeds 10 days should be identified. A daily list should be provided to the quality assurance manager indicating the reason/s for the extended stay. The quality assurance manager should develop an appropriate plan based on a case-to-case basis.
REVIEWERCheck for reports that patient stays exceeding 10 days are investigated.
There is no checklist for this element
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Component 3: Clinical Governance
Sub-component 12: Infection prevention and control
COMMITMENT FOR SUB-COMPONENT 12: Monitor adherence to prescribed infection prevention and control policies and procedures
The responsibility for this sub-component lies with the Hospital Corporate Services- Executive Management and more specifically the Clinical
Management (Medical and Nursing).
ELE
ME
NTS
84 National Policy on Infection Prevention and Control is available
NB 85 SOP for Infection Prevention and Control practices is adhered to
86 Hand hygiene practices are monitored
87 Poster on cough etiquette is displayed
88 Staff wear appropriate personal protective gear
NB 89 Linen in use is clean
90 SOP for handling linen in use is adhered to
91 Waste is properly segregated
92 Sharps are managed appropriately
93 Sterile Milk kitchen adheres to infection prevention and control practices
Vital Essential NB Important
Who is responsible for this sub-component?
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Element 84: National Policy on Infection Prevention and Control is available
RESP
ONS
IBLE PERSON
Ensure that the hospital has a hard or electronic copy of the National Policy on Infection Prevention and Control (available from www.health.gov.za).
REVIEWERVerify that the hospital has a copy of the National Policy on Infection Prevention and Control.
There is no checklist for this element
NB Element 85: SOP for Infection Prevention and Control practices is
adhered to
RESP
ONS
IBLE PERSON
Develop a hospital specific SOP for infection prevention control that is aligned to the national policy. This SOP must include amongst others the standard precautions to be adhered to, management and transport of patients with suspected communicable diseases; as well as the procedure to be followed for needle stick injuries. The infection control practitioner must regularly monitor that infection prevention and control practices in all clinical and non-clinical service areas.
REVIEWER Obtain reports of IPC. Interview staff and ask them to explain how standard precautions are applied; how patients with suspected communicable diseases are managed and transported and procedures for needle stick injuries.
CHECKLIST FOR ELEMENT 85
SOP FOR INFECTION CONTROL PRACTICES IS ADHERED TO
Description Score
Standard precautions adhered to
Management of patients with communicable diseases (including transport)
Needle stick injuries
Total score
Maximum possible score
Percentage score %
Element 86: Hand hygiene practices are monitored
RESP
ONS
IBLE PERSON
Healthcare practitioners must comply to the five moments for hand hygiene- before patient contact; before aspetic task; after body fluid exposure or risk; after patient contact and after contact with patients surrounding. The infection control practitioner must ensure that hand hygiene is practiced correctly by all healthcare workers; and that patients are educated on hand hygiene.
REVIEWER
Obtain for reports of hand hygiene audits conducted in the previous 6 months. The reports must indicate the compliance and action plan to improve compliance.
There is no checklist for this element
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 87: Poster on cough etiquette is displayed
RESP
ONS
IBLE PERSON
Ensure that the hospital has posters on cough etiquette (available from www.health,gov.za). The poster should be displayed in all waiting areas and in wards.
REVIEWER Observe if the posters are displayed in all waiting areas and wards.
There is no checklist for this element
Element 88: Staff wear appropriate personal protective gear
RESP
ONS
IBLE PERSON Personal protective clothing (gloves; disposable gown or aprons; protective face shields and safety boots) are an important aspect of infection prevention. It is important that staff wear the necessary personal protective gear to reduce their risk of acquiring an infection.
REVIEWER Randomly select 5 doctors or nurses, 2 radiographers, 2 mortuary staff and check if staff are using appropriate personal protective gear.
CHECK IN THESE
FUNCTIONAL AREAS
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
CHECK IN THESE
FUNCTIONAL AREAS
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CHECKLIST FOR ELEMENT 88
STAFF WEAR APPROPRIATE PROTECTIVE CLOTHING
Description Score
Gloves – non sterile
Gloves – sterile
Disposable gowns OR aprons
Protective face shields OR goggles with surgical face masks
Safety boots
Score
Maximum possible score
Total score for all stock available and worn by staff
NB Element 89: Linen in use is clean
RESP
ONS
IBLE PERSON Ensure that the hospital has a hard or electronic copy of the National Cleanliness Guideline that has a chapter on the management of linen (available from www.health.gov.za). The linen in use must be clean; used for its intended purpose at all times and should not be torn.
REVIEWERObserve that linen in use in all clinical and health support service areas, wards, theatres and emergency services are clean, appropriately used and not torn.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Rehabilitative and Palliative Care
Radiology
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 90: SOP for handling linen in use is adhered to
RESP
ONS
IBLE PERSON
Ensure that the hospital must have an SOP for the handling of linen in use that is aligned to the National Cleanliness Guidelines and Infection Prevention and Control Policy. Linen include mattresses; bed covers; pillow covers; bed sheets; towels; blankets; doctors coat; table covers blanket screens. The SOP must include the following:
All clean linen must be:
• stored in a clean, closed cupboard (either a dedicated linen cupboard or dedicated, fully enclosed mobile linen trolley)
• stored off the floor
• stored with the linen cupboard/trolley doors closed to prevent airborne contamination
• stored in a clean, dust free environment
• segregated from used / soiled linen • At ward level no more than 24 hours supply of linen should be stored • Clean linen must not be stored in unsuitable areas e.g. the sluice, bathrooms,
in bed spaces.
REVIEWERObserve the process for handling clean linen. Verify that the hospital has a procedure for handling linen. Ask a staff member to explain how linen is use is handled to verify implementation of the SOP.
There is no checklist for this element
Element 91: Waste is properly segregated
RESP
ONS
IBLE PERSON The hospital must have an SOP for the management of waste. The SOP must include segregation of general waste, infectious, hazardous and radioactive medical waste. Waste segregation posters should be displayed in a prominent position at all waste generation points.
REVIEWER
Observe if waste is segregated correctly in all clinical service areas.
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Rehabilitative and Palliative Care
Radiology
CHECK IN THESE
FUNCTIONAL AREAS
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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CHECKLIST FOR ELEMENT 91
WASTE IS PROPERLY SEGREGATED
Description Score
General health-care waste should join the stream of domestic refuse for disposal
Sharps should be collected in yellow puncture-proof containers
Bags and containers for infectious waste should be marked with the international infectious substance symbol
Cytotoxic waste, most of which is produced in major hospital or research facilities, should be collected in strong, leak-proof containers clearly labelled “Cytotoxic wastes”
Chemical or pharmaceutical waste may be collected together with infectious waste
Other infectious waste, pathological and anatomical waste should be collected in Leak-proof plastic bag or conatiners
Score
Maximum possible score (sum of all scores minus the ones marked NA)
Total score for all stock available and worn by staff
Element 92: Sharps are managed appropriately
RESP
ONS
IBLE PERSON Ensure that sharps are disposed of in an impenetrable tamperproof container and the containers are placed on work surface or wall-mounted. The sharp containers must be disposed off when they reach the limit mark. Green containers are available for pharmaceutical waste.
REVIEWER
Assess if sharps are being managed appropriately in all clinical service areas (Sharp 92).
CHECKLIST FOR ELEMENT 92
SHARPS ARE MANAGED APPROPRIATELY
Description Score
Sharps are disposed of in impenetrable, tamperproof containers
Sharps containers are disposed of when they reach the limit mark
Sharps containers are placed on work surface or in wall mounted brackets
Green waste recepticles for pharmaceutical waste ae available
Score
Maximum possible score
Total score for all stock available and worn by staff
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Rehabilitative and Palliative Care
Radiology
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 93: Sterile Milk kitchen adheres to infection prevention and control practices
RESP
ONS
IBLE PERSON
The SOP on infection prevention and control must include the sterile milk kitchen. It is important that the milk kitchen is designed in accordance with infection control principles and that staff adhere to infection prevention and control practices such as a clean and dirty area separated by a physical barrier; hand basin with elbow operated taps; kettle or urn; covered trolley for transporting feeds and separate cleaning equipment for use in milk kitchen.
REVIEWER
Assess if the milk kitchen adheres to infection prevention and control principles.
CHECKLIST FOR ELEMENT 93
STERILE MILK KITCHEN ADHERES TO INFECTION PREVENTION AND CONTROL PRACTICES
Description Score
The milk kitchen must have two functional areas- clean and dirty separated by a physical barrier
Hand basin with elbow operated taps in each areas
A kettle or urn for boling water
A losed or covered trolley for transporting feeds
Separate cleaning equipment for use in milk kitchen only
Score
Maximum possible score
Total score for all stock available and worn by staff
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Component 4: Diagnostic and Therapeutic Services
Sub-component 13: Therapeutic services
COMMITMENT FOR SUB-COMPONENT 13: Monitor consistent availability and management of medicines, blood and blood products, consumables and assistive devices.
The responsibility for this sub-component lies with the executive management and the pharmacy manager.
ELE
ME
NTS
94 Licence for Pharmacy issued by the Director-General of the National Department of Health is visibly displayed
95 Certificate of registration of the pharmacy with the South African Pharmacy Council and proof that payment of the annual fee is up- to- date is visibly displayed
96 Certificate of registration of the responsible pharmacist of the hospital with the South African Pharmacy Council is visibly displayed
NB 97 SLA between the hospital and the provincial depot/service supplier for the provision of medicines is available
NB 98 Good Pharmacy Practice Guidelines is available
99 Minimum GPP standards for pharmacy premises, facilities and equipment are adhered to
100 Minimum GPP standards for services offered in a Pharmacy adhered to
101 An electronic stock management system is used to manage medicine inventory
102 90% of the medicines on the hospital tracer medicine list are available
103 Essential medication for accident and emergency unit is available
104 Cold chain pr ocedure for vaccines is maintained
105 Basic medical supplies (consumables) are available
106 Emergency blood supplies are available
107 Clinicians have access to blood products
NB 108 Patients have access to assistive devices, orthotics and prosthetics
Vital Essential NB Important
Who is responsible for this sub-component?
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Element 94: Licence for Pharmacy issued by the Director-General of the National Department of Health is visibly displayed
RESP
ONS
IBLE PERSON Ensure that the hospital has a licence for the Pharmacy issued by the Director General; certificate of registration with the Pharmacy council with annual fees paid and the certificate of registration of the responsible pharmacist. All three certificates must be displayed in the Pharmacy manager’s office or a suitable place within the pharmacy
REVIEWERObserve if the licence certificate; certificate of registration with payment of the annual fee and the certificate of registration of the responsible pharmacist is displayed and current.
There is no checklist for this element
Element 95: Certificate of registration of the pharmacy with the South African Pharmacy Council and proof that payment of the annual fee is up- to- date is visibly displayed
RESP
ONS
IBLE PERSON Ensure that the hospital has a licence for the Pharmacy issued by the Director General; certificate of registration with the Pharmacy council with annual fees paid and the certificate of registration of the responsible pharmacist. All three certificates must be displayed in the Pharmacy manager’s office or a suitable place within the pharmacy
REVIEWERObserve if the licence certificate; certificate of registration with payment of the annual fee and the certificate of registration of the responsible pharmacist is displayed and current.
There is no checklist for this element
Element 96: Certificate of registration of the responsible pharmacist of the hospital with the South African Pharmacy Council is visibly displayed
RESP
ONS
IBLE PERSON Ensure that the hospital has a licence for the Pharmacy issued by the Director General; certificate of registration with the Pharmacy council with annual fees paid and the certificate of registration of the responsible pharmacist. All three certificates must be displayed in the Pharmacy manager’s office or a suitable place within the pharmacy
REVIEWERObserve if the licence certificate; certificate of registration with payment of the annual fee and the certificate of registration of the responsible pharmacist is displayed and current.
There is no checklist for this element
NB Element 97: SLA between the hospital and the provincial depot/
service supplier for the provision of medicines is available
RESP
ONS
IBLE PERSON Ensure that the hospital has a signed service level agreement with the provincial medicines depot and/or other service supplier that is current and signed for the provision of medicines. The pharmacy manager should have a copy of this SLA.
REVIEWER Verify that there is copy of the SLA in the pharmacy.
There is no checklist for this element
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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NB Element 98: Good Pharmacy Practice Guidelines is available
RESP
ONS
IBLE PERSON
Ensure that a hard or electronic copy of Good Pharmacy Practice (GPP) Guidelines (available from www.pharmcouncil.co.za) is available at the hospital
REVIEWER Verify that the pharmacy has a copy of the GPP guidelines.
There is no checklist for this element
Element 99: Minimum GPP standards for pharmacy premises, facilities and equipment are adhered to
RESP
ONS
IBLE PERSON
The hospital pharmacy should comply with standards stipulated in the Good Pharmacy Practice Guidelines. There are specific standards applicable to the pharmacy premises that include layout of the pharmacy; location of the pharmacy and storage areas. The temperature of the pharmacy should be controlled at 25°C; areas for equipment washing; storage of thermolabile medicines; calibration of refrigerators; protection of products from adverse effects of lighting and temperature extremes.
REVIEWERAssess if the pharmacy meets the GPP standards for pharmacy premises, facilities and equipment.
CHECKLIST FOR ELEMENT 99
MINIMUM GPP STANDARDS FOR PHARMACY PREMISES, FACILITIES AND EQUIPMENT ARE ADHERED TO
Description ScoreThe design and layout of the pharmacy must permit a logical flow of work and must minimise the risk of errors and cross-contamination
Storage of thermolabile medicines must be in accordance with the storage instructions of the manufacturer.
Refrigerators used for the storage of thermolabile medicine must be calibrated regularly
Products must be protected from the adverse effects of light, freezing or other temperature extremes and dampness There must be an area where equipment and other utensils can be washed which has a source of hot and cold tap water.
The pharmacy must be located in an area easily accessible to patients and staff of the hospital
Storage areas must be large enough to allow for orderly arrangement of stock and proper stock rotation The temperature in the dispensing area must be maintained below 25°C and there must be an air-conditioner installed in the dispensary that is in good working order.
There must be suitable dispensing equipment
Total score
Total maximum possible score
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 100: Minimum GPP standards for services offered in a Pharmacy adhered to
RESP
ONS
IBLE PERSON
Ensure that the hospital adheres to standards for services offered at the pharmacy. These standards are to ensure that medicines are stored and dispensed appropriately and to ensure a constant supply of the required medicines. The standards include that the distribution of medicines takes place under the control of a pharmacist, attendance of a pharmacist on ward rounds and the establishment and maintenance of stock-lists.
REVIEWER Observe that the distribution of medicines is under control of pharmacist. Verify a stock list exits for all wards and theatres. Request a copy of the stock monitoring index for all areas where medicines are stored. Ask doctors if pharmacist accompany them on ward rounds.
CHECKLIST FOR ELEMENT 100
MINIMUM GPP STANDARDS FOR SERVICES OFFERED IN A PHARMACY ARE ADHERED TO
Description Score
Distribution of medicines must take place under the direction and control of a pharmacist
A stock list must be available for wards and theatres
A copy of the stock list must be made available to nursing staff who will be responsible for obtaining supplies of stock, and to prescribers servicing the ward
Regular stock checking by pharmacy personnel must be undertaken at least monthly to ensure that stock rotation is maintained in all medicine storage areas in the hospital/
Pharmacist must attend ward rounds
Total score
Total maximum possible score
Percentage score %
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Element 101: An electronic stock management system is used to manage medicine inventory
RESP
ONS
IBLE PERSON The hospital pharmacy must have a functional electronic stock management system. Update the electronic networked system at minimum on a weekly basis. Access to the capturing device should be restricted.
REVIEWER Observe that the hospital has an electronic medicine stock management system. Verify that the capturing system is in good working order and has access control. Requets to see the last date of report that submitted.
CHECKLIST FOR ELEMENT 101
AN ELECTRONIC STOCK MANAGEMENT SYSTEM IS USED TO MANAGE MEDICINE INVENTORY
Description Score
The facility has functional electronic networked system for monitoring the availability of medicines
The approved list of medicines to be updated is visible in the medicine room.
The facility updates the electronic networked system at least weekly
The capturing device and its accessories are in good working order.
The capturing device and its accessories are stored in a lockable unit.
Access to the keys for the unit where the capturing device is kept is restricted.
The facility has not been marked as non-reporting for two weeks (10 working days) or more (at the point of assessment).*
Total score
Total maximum possible score
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 102: 90% of the medicines on the hospital tracer medicine list are available
RESP
ONS
IBLE PERSON The pharmacy should keep a list of the medicines that are required based on the defined package of services offered at the hospital. Obtain the list of medicines for district hospitals, from the Essential Drug List (EDL). Monitor the Stock of tracer medicines weekly.
REVIEWER
Conduct a spot check to determine the availability of tracer medicines.
CHECKLIST FOR ELEMENT 102
90% OF THE MEDICINES ON THE DISTRICT HOSPITAL TRACER MEDICINE LIST ARE AVAILABLE
MEDICINE ROOM/DISPENSARY
Oral formulations/inhalers Score
Abacavir 20mg/mL (240 ml) syrup
Abacavir 60mg tablets
Amlodipine 5mg tablets
Amoxicillin 250mg OR 500mg capsules
Amoxicillin suspension 125mg/5ml OR 250mg/5mL
Aspirin 300mg tablets
Azithromycin 250mg OR 500mg tablets
Beclomethasone 100mcg or 200 mcg inhaler
Carbamazepine 200mg tablets OR lamotrigine 25mg tablets
Co-trimoxazole 200/40mg per 5ml 50ml OR 100ml suspension
Co-trimoxazole 400/80mg tablets
Efavirenz 200 mg capsules
Efavirenz 50mg capsules
Enalapril 10mg tablets
Ferrous lactate/gluconate suspension
Ferrous sulphate/fumarate tablets providing ± 65mg elemental iron
Folic acid 5 mg tablets
Hydrochlorothiazide 12.5mg OR 25mg tablets
Ibuprofen 200 mg OR 400mg tablets
Isoniazid 100mg OR 300mg tablets
Lamivudine 10mg/mL (240ml) syrup
Lamivudine 150mg tablets
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CHECKLIST FOR ELEMENT 102
90% OF THE MEDICINES ON THE DISTRICT HOSPITAL TRACER MEDICINE LIST ARE AVAILABLE
MEDICINE ROOM/DISPENSARY
Lopinavir, Ritonavir 200/50mg tablets
Lopinavir, Ritonavir 80/20mg/mL (60 ml)
Metformin 500mg OR 850mg tablets
Methyldopa 250 mg tablets
Metronidazole 200mg OR 400mg tablets
Nevirapine 200mg tablets
Nevirapine 50mg/5ml suspension
Oral rehydration solution
Paracetamol 120mg/5ml syrup
Paracetamol 500mg tablets
Prednisone 5mg tablets
Pyrazinamide 500mg tablets
Pyridoxine 25mg tablets
Rifampicin + Isoniazid (RH) 300mg/150mg OR 150/75mg tablets
Rifampicin + Isoniazid (RH) 60/60 tablets
Rifampicin + Isoniazid + pyrazinamide + ethambutol (RHZE) (150/75/400/275) tablets
Salbutamol inhaler
Simvastatin 10mg tablets
Tenofovir, Emtricitabine 300/200 mg tablets
Tenofovir/emtricitabine/efavirenz 300/200/600mg tablets
Vitamin A 50 000U OR 100 000U OR 200 000U capsule
Zidovudine 50mg/5mL, 200 ml suspension
Injections
Benzathine benzylpenicillin 2.4MU vial
Ceftriaxone 500mg OR 1g ampoules
Medroxyprogesterone acetate 150mg/ml injection OR norethisterone 200mg/ml
Topicals
Chloramphenicol 1%, ophthalmic ointment
Fridge
BCG vaccine
Insulin, short acting
Measles vaccine
Hexavalent: DTaP-IPV-HB-Hib vaccine
Oxytocin 5 OR 10 IU/ml OR oxytocin/ergometrine combination)
Pneumococcal Conjugated Vaccine (PCV)
Polio vaccine (oral)
Rotavirus vaccine
Tetanus toxoid (TT) vaccine
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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CHECKLIST FOR ELEMENT 102
90% OF THE MEDICINES ON THE DISTRICT HOSPITAL TRACER MEDICINE LIST ARE AVAILABLE
MEDICINE ROOM/DISPENSARY
Emergency trolley
Adrenaline Injection 1mg/ml (Epinephrine)
Amlodipine 5 OR 10mg tablets
Dextrose 10% OR 50% intravenous solution
Furosemide 20mg ampoule
Hydrocortisone sodium succinate 100mg/ml
Isosorbide dinitrate, sublingual, 5 mg tablets
Magnesium sulphate 50%, 2ml ampoule
Midazolam (1mg/ml OR 5mg/ml) OR Diazepam 5mg/ml
Nifedipine 10mg capsules
Promethazine HCl 25mgampoule
Sodium chloride 0.9% 1L
Total score /67
Percentage score %
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Element 103: Essential medication for accident and emergency unit is available
RESP
ONS
IBLE PERSON Essential medication is a pre-requisite for effective patient management. A list of minimum medication required for the accident and emergency unit must be available based on the Standard Treatment Guidelines.
REVIEWER
Assess whether essential medication is available at the accident and emergency unit.
CHECKLIST FOR ELEMENT 103
ESSENTIAL MEDICATION FOR ACCIDENT AND EMERGENCY UNIT IS AVAILABLE
Description Score
Adrenaline Injection 1mg/ml
Furosemide 20 mg injection
Gentamicin 80mg injection
Haloperidol injection
Halothane
Heparin (unfractionated) injection
Hydrocortisone injection
Ibuprofen tablets 200mg
Insulin soluble 100iu/ml
Lopinavir/ritonavir syrup or paediatric tablets
Magnesium sulphate injection
Budesonide or Beclomethasone inhaler
Metformin tablets 500mg or 850mg
Morphine injection
Moxifloxacin 400mg tablet
Omeprazole tablets
Oxytocin injection 5iu or 10iu
Paracetamol 50ml or 100ml syrup 120mg/5ml
Paracetamol tabs 500mg
Prednisone 5mg tablets
Salbutamol UDV
Simvastatin 10mg
Carbamazepine 200 mg tablets
Sodium Chloride 0.9% 1L
Tenofovir + emtricitabine/lamivudine + efavirenz as FDCs
Ceftriaxone 250 mg or 500 mg or 1000mg injection
Dextrose 50% 20 ml injection
Diazepam injection 10mg/2ml
Dobutamine or dopamine injection
Enalapril or Perindopril tablets
Fluoxetine 20 mg capsule
Total Score for all
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 104: Cold chain procedure for vaccines is maintainedRE
SPO
NSIBLE PERSON Maintaining the correct temperature of vaccines is a fundamental component of
vaccine efficacy. It is therefore important that vaccines are transported and maintained at the correct temperature from the time of dispatch to the hospital until the vaccine is administered to the patient.
REVIEWERCheck that there is a refrigerator for storing vaccines with the temperature recorded twice daily, and that there is a cooler box and ice packs for storage or transportation if needed.
There is no checklist for this element
Element 105: Basic medical supplies (consumables) are available
RESP
ONS
IBLE PERSON A list of basic medical supplies required for the level of hospital must be available and re-order levels for each item must be determined. The stock must be monitored weekly.
REVIEWERConduct a spot check to assess whether basic medical supplies (consumables) are available.
CHECKLIST FOR ELEMENT 105
BASIC MEDICAL SUPPLIES (CONSUMABLES) ARE AVAILABLE
SURGICAL SUPPLIES
Item Score
Admin set 20 drops/ml 1.8m /pack
Admin set paeds 60 drops/ml 1.8m /pack
Blade stitch cutter sterile/pack
Blood collecting vacutainer (holding barrel/bulldog)
Blood lancets (haemolance)
Urinary (Foley’s) catheter silicone/latex 8f
Urinary (Foley’s) catheter silicone/latex 10f
Urinary (Foley’s) catheter silicone/latex 12f
Urinary (Foley’s) catheter silicone/latex 14f
Urinary (Foley’s) catheter silicone/latex 16f
Urinary (Foley’s) catheter silicone/latex 18f
Urinary (Foley’s) catheter silicone/latex 20f
Urinary (Foley’s) catheter silicone/latex 22f
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
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CHECKLIST FOR ELEMENT 105
BASIC MEDICAL SUPPLIES (CONSUMABLES) ARE AVAILABLE
SURGICAL SUPPLIES
Item Score
Catheter suction resp 500mm 06f
Catheter suction resp 500mm 08f
Catheter suction resp 500mm 10f
Catheter suction resp 500mm 12f
Catheter suction resp 500mm 14f
Catheter thoracic silicone st20
Catheter thoracic silicone st24
Catheter thoracic silicone st28
Catheter thoracic silicone st30
Catheter thoracic silicone st32
Drainage sys chest u/water adult
Urine drainage bag
Simple face mask OR reservoir mask OR nasal cannula (prongs) for oxygen, adults
Simple face mask OR reservoir mask OR nasal cannula (prongs) for oxygen, paediatric
Gloves exam n/sterile large /box
Gloves exam n/sterile medium /box
Gloves exam n/sterile small /box
Gloves surg sterile latex sz 6 OR6.5 OR Small/box
Gloves surg sterile latex sz 7OR 7.5 OR medium/box
Gloves surg sterile latex sz 8 OR large/box
Endotracheal tubes – uncuffed size 2mm OR 2.5mm
Endotracheal tubes – uncuffed size 3mm OR 3.5mm
Endotracheal tubes – uncuffed size 4.0mm OR 4.5mm
Endotracheal tubes – cuffed size 5.0mm
Endotracheal tubes – cuffed size 6.0mm
Tube stomach washout 24fg
Tube,stomach washout 26fg
Tube,stomach washout 28fg
Tube stomach washout 30fg
Sheath incontinence 25mm
Sheath incontinence 30mm
Sheath incontinence 35mm
Infusion set 19g
Infusion set 21g
Infusion set 23g
Infusion set ivac 590
Intravenous cannula(Jelco)18g green/box
Intravenous cannula(Jelco)20g pink/box
Intravenous cannula (Jelco)22g blue/box
Intravenous cannula (Jelco)24g yellow/box
Face mask for nebuliser OR face mask with nebuliser chamber for adult
Face mask for nebuliser OR face mask with nebuliser chamber for paediatric
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CHECKLIST FOR ELEMENT 105
BASIC MEDICAL SUPPLIES (CONSUMABLES) ARE AVAILABLE
SURGICAL SUPPLIES
Item Score
Nasogastric feeding tube 600mm fg5
Nasogastric feeding tube 600mm fg8
Nasogastric feeding tube 1000mm fg10 OR 12
Disposable aprons
Eye patches (disposable)
Disposable razors
Disposable Amnihook
Ultrasound gel medium viscosity
Dental syringe and needle for LA
Needles: 18 (pink) OR 20 (yellow)/box
Needles: 21 (green)/box
Needles: 22 (black)/box
Needles: 23 (blue)/box
Needles: 25 /box
* Syringes 3-part 2ml/box
* Syringes 3-part 5ml/box
* Syringes 3-part 10 ml/box
* Syringes 3-part 20ml/box
Insulin syringe with needle /box
Suture chromic g0/0 or g1/0 1/2 75cm
Suture nylon g2/0 or g3/0 3/8 45cm
Suture nylon g4/0 3/8 45cm
Self-retaining 4-wing catheters (de Pezzer), sizes 8, 14, 16, and 18 Ch.
Self-retaining balloon catheters (Foley), sizes 8, 14, 16, 18, and 22 Ch.
Urethral catheters (Nelaton), solid-tip, sizes 8, 10, 12, and 14 Ch.
Urethral catheters, coudé, sizes 8, 10, 12, 14, and 16 Ch.
Urinary bags
Graduated drainage (collecting) bottles, glass, 1.5 litre
Colostomy bags
Washable footwear, antistatic
Drapes
Gowns
Surgeon’s handbrushes with nylon bristles
Regular-eye needles, assortment of different types and sizes
Scalpel blades, No. 10, 11,17, 15,21, 22, 23
Aneurysm needles:
Stitch removal scissors
Heavy-duty “counter” scissors
Cannulas: stainless-steel
Disposable scalp-vein infusion sets
Polythene tubing, 0.86 mm inner diameter, 1.27 mm outer diameter
Polythene tubing, 1.40 mm inner diameter, 1.90 mm outer diameter
Polythene tubing, 1.67 mm inner diameter, 2.42 mm outer diameter
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CHECKLIST FOR ELEMENT 105
BASIC MEDICAL SUPPLIES (CONSUMABLES) ARE AVAILABLE
SURGICAL SUPPLIES
Item Score
Gauze bandage:
Absorbent gauze (for dressings, swabs, abdominal packs, petrolatum gauze, etc.):
Linen tape:
Surgical adhesive tape, 25 mm ×10 m
Adhesive zinc oxide tape, 75 mm ×5 m
Non-adhesive elastic bandage, 7 5 mm × 5m
Absorbent cotton wool
Eye pads
Eye shields
Umbilical tape, 3 mm wide
Indelible pencils
Safety pins, medium size
Rubber bands, assorted
Garters, elasticated
Manually operated hair clippers, narrow
Clipboards, 23 ×32 cm
All-metal safety razors, 3-piece
Double-edged safety-razor blades
Battery-operated wall clock, with hands showing time in seconds, minutes, and hours
Replacement pads for AED - adult (Only applicable if facility uses an Automatic External Defibrillator (AED))
Replacement pads for AED - paediatric (Only applicable if facility uses an Automatic External Defibrillator (AED))
Plaster roll
Bandage crepe
Gauze paraffin 100x100 /box
Gauze swabs plain n/s 100x100x8ply/pack
* Gauze abs grade 1 burn 225x225x16 /pack
Basic disposable dressing pack(should contain as a minimum cotton wool balls, swabs, 2 forceps, disposable drape)
Cotton wool balls 1g 500`s
* Padding cast ortho 50mmx3m /roll
* Padding cast ortho 100mmx3m /roll
* Padding cast ortho 150mmx3m /roll
* Plaster of paris bandage 100mm /roll
* Plaster of paris bandage 150mm /roll
* Plaster of paris bandage 200mm /roll
* Skin traction kit - adult (elast 0468)
* Skin traction kit - child (elast 0469)
* Sodium carboxymethylcel (intrasite) 15g
Sanitary towels maternity /pack
Stockinette 100mm OR150mm/roll
Adhesive micro-porous surgical tape 24/25mm or 48/50mm
70% isopropyl alcohol prep Pads 24x30 1ply OR 2 ply /box
Gauze abs grade 1 burn /pack
Gauze bandages, 10 cm and 15 cm wide
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CHECKLIST FOR ELEMENT 105
BASIC MEDICAL SUPPLIES (CONSUMABLES) ARE AVAILABLE
SURGICAL SUPPLIES
Item Score
Crepe bandages
Stockinet, assorted sizes
Plaster of Paris powder (anhydrous calcium sulfate)
Triangular cloth bandages (for arm slings)
Thomas splints:
Pearson attachments for Thomas splints:
Half-ring Thomas splints:
Multi-purpose board splints, 3 sizes
Cramer wire splints: narrow, medium, and wide
Total score for surgical and dressing supplies
Total maximum score for surgical supplies (sum of all scores minus those marked NA) and dressing supplies
Percentage score %
Element 106: Emergency blood supplies are available
RESP
ONS
IBLE PERSON
The hospital must maintain a supply of blood for emergencies. This blood must be available on-site and stored in a designated refrigerator.
REVIEWERConduct a spot check to assess whether emergency blood supplies are available and stored correctly.
CHECKLIST FOR ELEMENT 106
EMERGENCY BLOOD SUPPLIES ARE AVAILABLE
Description Score
Emergency blood supplies are available on site
Emergency blood is stored in a designated refrigerator which is accessible 24 hours
Total Score for all
Percentage score %
Element 107: Clinicians have access to blood products
RESP
ONS
IBLE PERSON
The hospital should have a process for clinicians to access blood products. The hospital may have a blood bank office on-site or contact details for the local SANBS office.
REVIEWERCheck for documentation of the process to follow to access blood products. Ask a clinician to explain the process of accessing blood products.
There is no checklist for this element
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NB Element 108: Patients have access to assistive devices, orthotics and
prostheticsRE
SPO
NSIBLE PERSON
The hospital must have a referral pathway for patients to access assistive devices, orthotics and prosthetics that are not available on-site.
REVIEWERAssess whether patients have access to assistive devices, orthotics and prosthetics.
Checklist 108
CHECKLIST FOR ELEMENT 108
PATIENTS HAVE ACCESS TO ASSISTIVE DEVICES, ORTHOTICS AND PROSTHESES
Patients are issued with assistive devices Onsite Referred
Wheel chairs
Glasses
Walking Aids
Orthotics
Prosthetics
Total Score for all
Percentage score %
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Component 4: Diagnostic and Therapeutic Services
Sub-component 14: Diagnostic services
COMMITMENT FOR SUB-COMPONENT 14: Monitor consistent availability, safety and use of laboratory and imaging services
Executive Management, shared with Laboratory Services and Radiology
ELE
ME
NTS
NB 109 The servicing NHLS laboratory is accredited
110 The National NHLS Handbook is available
NB 111 Essential laboratory list for hospitals based on level of care is available
NB 112 90% of tests requested comply with the ELL
113 Required functional diagnostic equipment and concurrent consumables for point of care testing are available
114 Required specimen collection materials and stationery are available
115 Specimens are collected, packaged, stored and prepared for transportation according to the National NHLS Handbook
116 Laboratory results are received from the laboratory within the specified turnaround times
117 The imaging services is accredited
118 Emergency imaging services are available for 24 hours on site
119 Functional portable x-ray unit available 24 hours
120 Basic imaging services are available for a minimum of 8 hours, 5 days a week on site
121 Access to specialist imaging reporting services
122 Required functional diagnostic equipment and concurrent consumables for radiography services are available
123 Required functional diagnostic equipment and concurrent consumables for ultrasonography services are available
124 Required functional diagnostic equipment and concurrent consumables for health support services are available
125 Appropriate radiography signage is visibly displayed
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 109: The servicing NHLS laboratory is accredited
RESP
ONS
IBLE PERSON Laboratory services are an important component of patient care. A laboratory must be accredited to ensure that proper quality assurance mechanism are in place and to facilitate the good laboratory practice.
REVIEWERVerify that NHLS laboratory that services the hospital is accredited- Request the NHLS to provide the certificate or letter.
There is no checklist for this element
Element 110: The National NHLS Handbook is available
RESP
ONS
IBLE PERSON
Ensure that the hospital and servicing laboratory must have a hard or electronic copy of the National NHLS handbook (available from www.health.gov.za).
REVIEWER Verify that the hospital laboratory has the National NHLS Handbook.
There is no checklist for this element
NB Element 111: Essential laboratory list for hospitals based on level of
care is available
RESP
ONS
IBLE PERSON Ensure that there is an essential list of laboratory tests available for the hospital based on the level of care
REVIEWERVerify that the hospital has a list of essential laboratory tests for the level of the hospital.
There is no checklist for this element
NB Element 112: 90% of tests requested comply with the ELL
RESP
ONS
IBLE PERSON An electronic monitoring system should be in place to capture all laboratory tests carried out per hospital. This monitoring system must be able to identify the proportion of tests that are on the ELL.
REVIEWERRequest reports for the last 3 months of all laboratory tests conducted by the hospital with a report on non-ELL tests to assess whether at least 90% of laboratory test comply with the ELL.
There is no checklist for this element
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Element 113: Required functional diagnostic equipment and concurrent consumables for point of care testing are available
RESP
ONS
IBLE PERSON An essential set of diagnostic equipment such as Hb meters; blood glucometer, malaria rapid test; HIV rapid test and Rhesus factor test and its concurrent consumables to conduct point of care testing must be available at the hospital.
REVIEWERVerify whether the facility has the required equipment and concurrent consumables to conduct point of care testing as listed in Checklist 113.
CHECKLIST FOR ELEMENT 113
REQUIRED FUNCTIONAL DIAGNOSTIC EQUIPMENT AND CONCURRENT CONSUMABLES FOR POINT OF CARE TESTING ARE AVAILABLE
Item Score
Laboratory equipment and consumables
Hb meter
Blood glucometer
Spare batteries for blood glucometer
Glass slides for cervical smears
Lancets
Blood glucose strips
Urine dipsticks
Urine specimen jar OR flask
Malaria rapid test (where applicable in facilities in KZN, GP, MP and LP)
Rapid HIV test
Rh ‘D’ (Rhesus factor) test
Total score for all (Total score laboratory equipment + consumables + stationery)
Total maximum possible score
Percentage score %.
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Laboratory
CHECK IN THESE
FUNCTIONAL AREAS
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Element 114: Required specimen collection materials and stationery are available
RESP
ONS
IBLE PERSON Ensure that the hospital has a list of all specimen collection material and stationery required. Monitor the stock of these items weekly and re-order the items from the NHLS laboratory when the stock falls below minimum order quantity.
REVIEWERAssess that required specimen collection materials and stationery are available in all clinical service areas.
CHECKLIST FOR ELEMENT 114
REQUIRED SPECIMEN COLLECTION MATERIALS AND STATIONERY ARE AVAILABLE
Item Score
Vacutainer tube: Blue Top (Sodium Citrate)
Vacutainer tube: Red OR Yellow Top (SST)
Vacutainer tube: Yellow Top (SST-Paeds)
Vacutainer tube: Grey Top (Sodium Fluoride)
Vacutainer tube: White Top
Vacutainer tube: Purple Top (EDTA)
Vacutainer tube: Purple Top (EDTA Paeds)
Sterile specimen jars
Swabs with transport medium (Score NA if there is not a permanent doctor)
Sterile Tubes (without additive) for MCS (Microscopy, culture and sensitivity)(Score NA if there is not a permanent doctor)
Venipuncture needles (Green)
Specimen Plastic Bags
Pap smear collection materials
Fixative
Wooden spatula
Slide holder OR brown envelope
Microscope slides
Early Infant diagnosis (EID) collection material
DBS PCR Kit
NHLS STATIONERYRequest Form
Cytology Request Form
Order Book Material for specimen collection
Facility Specimen Register
Total Score
Percentage score %
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Laboratory
CHECK IN THESE
FUNCTIONAL AREAS
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Element 115: Specimens are collected, packaged, stored and prepared for transportation according to the National NHLS Handbook
RESP
ONS
IBLE PERSON
The process for collection, packaging, storage and transportation of specimens is specified in the National NHLS Handbook. There are three different categories of specimens. Ensure that for each category of specimen, the specimens are collected, packaged, stored and prepared according to the NHLS guidelines. It is important that all staff involved in specimen collection and transport are trained on the handling of specimens as this can affect the quality of the specimen.
REVIEWER
Conduct an assessment on three randomly selected samples from the three different category of samples to assess whether specimens are collected, packaged, stored and prepared for transportation correctly in all clinical service areas. Observe whether the specimens are labelled correctly, the correct requisition form is completed, specimens are kept away from sunlight; stored at room temperature or refrigerator if temperature exceeds 25°C. The appropriate transport medium must be used.
CHECKLIST FOR ELEMENT 115
SPECIMENS ARE COLLECTED, PACKED, STORED AND PREPARED FOR TRANSPORTATION ACCORDING TO THE PRIMARY HEALTH CARE LABORATORY HANDBOOK
Group A Group B Group C
Item
Sco
re
sam
ple
1
Sco
re
sam
ple
2
Sco
re
sam
ple
3
Sco
re
sam
ple
1
Sco
re
sam
ple
2
Sco
re
sam
ple
3
Sco
re
sam
ple
1
Sco
re
sam
ple
2
Sco
re
sam
ple
3
GENERAL
Specimens are clearly labelled
Each laboratory request form is correctly completed
There is at least one functional wall mounted thermometer in area for lab specimens are stored for courier collection
The temperature of the storage area for lab specimens is recorded daily
Samples are kept away from direct sunlight
Where the room temperature exceeds 25°C, samples are stored in the fridge (+- 5°C)
Length of storage does not exceed 24 hours, stored at room temperature 20-25°C
Stored at room temperature
Stored inside a slide carrier (envelope)
Samples placed into the transport medium provided (where appropriate)
Total score for all samples
Total maximum possible score
Percentage
Total score for element (Percentage/9)
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Element 116: Laboratory results are received from the laboratory within the specified turnaround times
RESP
ONS
IBLE PERSON There are designated turnaround tests for laboratory tests as specified in the National NHLS handbook. A delegated staff member should be responsible for monitoring the time taken to receive laboratory results.
REVIEWER Assess the records of three patients who have had recent laboratory tests and identify the average time taken to receive laboratory results. All routine blood, sputum, urine and stool test results must be obtained within 24 hours whether delays are identified and implementations planned to rectify this.
CHECKLIST FOR ELEMENT 116
THE LABORATORY RESULTS ARE RECEIVED FROM THE LABORATORY WITHIN THE SPECIFIED TURNAROUND TIMES
Item Turnaround time Score record 1
Score record 2 Score record 3
All Blood routine blood test results 24 hours
Blood results: Cholesterol, CRP (C-reactive protein), 24 to 48 hours
FT4 (Free Throxine 4), HbA1c (Glycated Haemoglobin), Phenytoin, lipase, PSA (Prostate specific hormone), Red Cell Folate, Triglycerides, TSH (Thyroid stimulating hormone), Vitamin B12, CD4 Count, RPR(Rapid Plasma Reagin test for syphilis), Hepatitis A, B or C
48- 120 hours
Blood results: HIV PCR for infants, Viral Load 48- 120 hours
Pap smear Variable depending on the result (4-6 weeks)
MCS (Microscopy, culture band sensitivity) 24-72 hours
Sputum: TB Between 5 days and 6 weeks
Sputum: Xpert MTB/RIF 24 hours
Stool 24 hours
Urine 24 hours
Total score for all samples
Total maximum possible score
Percentage
Total score for element (Percentage/3)
Element 117: The imaging services is accredited
RESP
ONS
IBLE PERSON Ensure that the imaging services (at district level this includes radiography and ultrasound) must have a valid accreditation certificate. Obtain this certificate from the Provincial authority
REVIEWERVerify that the hospital has an accreditation certificates for the imaging services at the hospital.
There is no checklist for this element
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Element 118: Emergency imaging services are available for 24 hours on site
RESP
ONS
IBLE PERSON
The hospital must provide emergency imaging services for the level of care 24 hours on site.
REVIEWERCheck the roster for imaging services to verify that emergency imaging services is offered 24 hours. Interview the radiology staff to confirm that emergency imaging service are offered for 24 hours.
There is no checklist for this element
Element 119: Functional portable x-ray unit available 24 hours
RESP
ONS
IBLE PERSON Ensure that the hospital has a functional portable x-ray unit that is available 24 hours an dcan provide radiology services for emergency patients and inpatients based on request from clinicians for bedside X rays.
REVIEWERObserve whether that a functional portable x-ray unit is available at the hospital. Interview inpatient staff and whether the portable x-ray unit is functional.
There is no checklist for this element
Element 120: Basic imaging services are available for a minimum of 8 hours, 5 days a week on site
RESP
ONS
IBLE PERSON The hospital must provide basic imaging services during the day from Mondays to Fridays. These imaging services will vary depending on the level of care provided at the hospital.
REVIEWERCheck for a roster to that shows that the basic imaging services are staffed for 8 hours a day from Monday to Friday.
There is no checklist for this element
Element 121: Access to specialist imaging reporting services
RESP
ONS
IBLE PERSON
District hospitals must have access to reporting services by a radiologist. Regional, tertiary and central hospitals should have a radiologist/s employed at the hospital.
REVIEWERAsk radiology staff if they have a specialist onsite and if not how do they access reporting services by a radiologist.
There is no checklist for this element
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Element 122: Required functional diagnostic equipment and concurrent consumables for radiography services are available
RESP
ONS
IBLE PERSON Ensure that the hospital has a list of all radiology services provided and the required equipment and consumables to offer such services. Based on service utilisation and the defined package of services provided procure all the required equipment and concurrent consumables.
REVIEWERAssess whether the required diagnostic equipment and consumables are available and functional for radiography services(Checklist 122).
CHECKLIST FOR ELEMENT 122
REQUIRED FUNCTIONAL DIAGNOSTIC EQUIPMENT AND CONCURRENT CONSUMABLES FOR RADIOGRAPHY SERVICES ARE AVAILABLE
Description Score
General X-ray unit/s
Screening unit/s
Drip stand, mobile/fixed
Mobile unit/s
Radiation Monitoring badges
X-ray Mobile Shield
Shield X-ray gloves
Shield- gonad-Male and Female
Spirometer-adult and Paeds
C-Arms
Protective Aprons, X-ray, set, lead with hanger
Daylight processors
Marker x-ray –L-R ,chromeplated,AP
Examination table
Darkrooms
Laser cameras
Oxygen-cylinder or piped with suitable regulator and flow meter –ready for use
Teleradiology
Film digitizer/s
Computer/s
X-ray Viewing Boxes
Total score for all
Total maximum possible score
Percentage score %
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Element 123: Required functional diagnostic equipment and concurrent consumables for ultrasonography services are available
RESP
ONS
IBLE PERSON Ensure that the hospital has a list of all ultrasonography services provided and the required equipment and consumables to offer such services. Based on service utilisation and the defined package of services provided procure all the required equipment and concurrent consumables.
REVIEWERAssess whether the required diagnostic equipment and consumables for ultrasonography are available and functional.
CHECKLIST FOR ELEMENT 123
REQUIRED FUNCTIONAL DIAGNOSTIC EQUIPMENT AND CONCURRENT CONSUMABLES FOR ULTRASONOGRAPHY SERVICES ARE AVAILABLE
Description Score
Ultrasound scanner
Ultrasound gel
Scanner bed
Operator seating
Disposable tissue paper
Total score
Maximum possible score
Element 124: Required functional diagnostic equipment and concurrent consumables for health support services are available
RESP
ONS
IBLE PERSON Ensure that the hospital has a list of all health support services provided and the required equipment and consumables to offer such services. Based on service utilisation and the defined package of services provided procure all the required equipment and concurrent consumables.
REVIEWER Assess whether the required diagnostic equipment and consumables are available for health support services- Optometry, Physiotherapy, Occupational therapy, Oral Health, Speech and Audiology.
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
CHECK IN THESE
FUNCTIONAL AREAS
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CHECKLIST FOR ELEMENT 124
REQUIRED FUNCTIONAL DIAGNOSTIC EQUIPMENT AND CONCURRENT CONSUMABLES FOR HEALTH SUPPORT SERVICES SERVICES ARE AVAILABLE
Description Physiotherapy Occupational therapy
Speech & Audiology Optometry
Arm- and leg baths
Assorted toys for play therapy and distraction
Blood pressure unit
Bobath – plinth wooden (platform)
Bobath roll
Crutches – aluminium and wooden
Dumbbells of various weights (0.5-10kg)
Exercise mats – light weight
Foot mat for balance (Wobble board)
Goniometer - small, med, large, finger goniometer
Gym mat
Hand exercisers (power web, theraballs,therapy putty, cones, digifix)
Hotpack heater with hot packs
Ice packs
Massager (vibrator) – large and small
Measuring tape
Quadrupod
Re-education board
Stethoscope
Tilt table
Walking frame-adult
Walking frame-child
Walking frames
Weights/sandbags
Wheelchairs
Wrist/ankle weights
Diagnostic set
Blood pressure monitor, electronic or manual
Instrument set, dressing
Parallel bars-adjustable fixed/portable
Patella hammer
Physiotherapy balls
Posture Mirror
Quadrupod
Treatment plinths – adjustable backrest6m Snellen Chart, Literate/ Alphabets x 01,6m Snellen Chart, Tumbling Oculus Trial Frame Adult x 01,
Oculus Trial Frame Paediatric x 01
Test Of Visual Perceptual Skills ( TVPS ) x 04
Horizontal Optometry/ Ophthalmic Prism Bar x 01
Optometry Trial Case x 01
Optometry Chair Adjustable x 01
Total score for all samples
Total maximum possible score
Percentage
Total score for element (Percentage/4)
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CHECKLIST FOR ELEMENT 124
REQUIRED FUNCTIONAL DIAGNOSTIC EQUIPMENT AND CONCURRENT CONSUMABLES FOR HEALTH SUPPORT SERVICES SERVICES ARE AVAILABLE
Oral Health Services
Consumables
Exodontia (tooth extraction) and minor oral surgery ScoreSurgical blades Cotton wool balls Dry socket alveolar paste Ethyl chloride Haemostat sponge Hydrogen peroxide Hypodermic needles (disposable) Saline solution Saliva ejectors (disposable) Sutures surgical Topical anaesthetic Local anaesthetic (with vasoconstrictor) Local anaesthetic (without vasoconstrictor)
Conservative (preventive) dentistry Fissure sealants Amalgam capsules Composite Fluoride gel Varnish cavity liner Prophylaxis paste Cements /liners (kalzinol, Dycal etc.) Articulating paper Cotton wool pellets Polyster strips (composite) Haemostatic liquid Glass ionomers Matrix band (narrow & wide) Polishing strips Gingival cord Polishing brushes Dental floss Fluoride trays Saliva ejectors Acid etch Dentin bonding agents
School outreach Toothpaste Toothbrushes
Instrument steriliserAvailable Functional
Dental LED lightAvailable Functional
Digital X-Ray Sensor SystemAvailable Intact
Lockable medicine trolleyAvailable Intact
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CHECKLIST FOR ELEMENT 124
REQUIRED FUNCTIONAL DIAGNOSTIC EQUIPMENT AND CONCURRENT CONSUMABLES FOR HEALTH SUPPORT SERVICES SERVICES ARE AVAILABLE
Equipment Quantity Score
Air motor
Contra angle with ball bearing latch head 1
Straight handpiece 1
High speed air handpiece 1
3-in-one syringe 1
Aspi-Jet 6 mobile suction 1
Curing light with 11mm tip 1
Digital amalgamator
Ultrasonic scaler 1
Water distiller 1
X-ray aprons 2
Dental elevators
Periosteal Elevator 2
Straight elevator Large 4
Straight elevator Medium 4
Straight elevator small 4
Coleman root elevator right 4
Coleman root elevator left 4
Coleman elevator straight 4
Warwick-James elevator left 2
Warwick-James elevator right 2
Cryers elevator right 4
Cryers elevator left 4
Dental extraction forceps
Upper anterior forceps Adult 6
Upper anterior forceps Paedodontic 6
Upper root forceps 2
Lower anterior forceps Adult 6
Lower anterior forceps Paedodontic 6
Lower root forceps 2
Upper pre-molar forceps 6
Upper pre-molar root forceps 2
Lower premolar forceps 6
Lower pre-molar root forceps 2
Upper left molar forceps Adult 6
Upper left molar forceps Paedodontic 6
Upper right molar forceps Adult 6
Upper right molar forceps Paedodontic 6
Conservative Instruments
Amalgam carrier plastic straight 2
Amalgam carrier plastic right angle 2
Amalgam carrier steel straight 2
Amalgam carrier steel right angle 2
Excavator 121/122 4
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CHECKLIST FOR ELEMENT 124
REQUIRED FUNCTIONAL DIAGNOSTIC EQUIPMENT AND CONCURRENT CONSUMABLES FOR HEALTH SUPPORT SERVICES SERVICES ARE AVAILABLE
Excavator 161/162 4
Handle Mouth Mirror 30
Mouth Mirrors to fit Handle Mouth Mirror 30
Dental Explorers/Probes Straight 30
Cotton and Dressing Tweezers 30
Needle holder 2
Ball burnisher 2.5-3.0mm 6
Amalgam carver 6
Flat plastic 6
Amalgam plugger 4
Thymozin 4
Gingival marginal trimmer 4
Bur Blocks 2
Bur brushes 2
Dappen dishes 6
Bib holders 2
Cotton pellet holder 2
Kidney dishes large 4
Kidney dishes small 4
Cotton wool holder 2
Waste receiver 2
Matrix retainer Siqueland Narrow 4
Matrix retainer Siqueland Wide 4
Cement spatula 2
Dental syringe Aspirating 20
Artery forceps 2
Tongue forceps 2
Wire ligature forceps 2
Needle holder 2
Scissors ligature 2
Scissors dissecting 1
Mouth gag 4
Protective glasses 4
Handle scalpel 2
Wax carver 2
Total score for all samples
Total maximum possible score
Percentage score
Total score for element (Percentage a (LINE 49)+ Percentage B (Line 183)/2 %
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Element 125: Appropriate radiography signage is visibly displayedRE
SPO
NSIBLE PERSON
Ensure that the radiography unit has appropriate warning signs in place to notify patients and visitors of the risks of radiation.
REVIEWERAssess that radiography signage to check whether it is appropriate and is visibly displayed.
CHECKLIST FOR ELEMENT 125
APPROPRIATE RADIOGRAPHY SIGNAGE IS VISIBLY DISPLAYED
Signage for the following: Score
Pregnant patients
Radioactive imaging
Do not enter
Total Score for all
Percentage score %
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Component 5: Human Resources for Health
Sub-component 15: Human Resources Organisation
COMMITMENT FOR SUB-COMPONENT 15: Monitor HRH capacity and utilisation
Executive management, shared between the Chief Executive Officer; Clinical Management and Human Resources Management
ELE
ME
NTS
NB 126 An approved organogram is available
127 Critical management positions in the organogram are filled
128 Critical clinical positions in the organogram are filled
NB 129 Specific support services have designated managers
NB 130 Clinical Staffing needs have been determined in line with WISN
NB 131 Non clinical staff component is determined according to service needs
NB 132 All clinical post are filled according to service needs
NB 133 All non-clinical post are filled according to service needs
134 Duty roster for all clinical and non-clinical service areas are available
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 126: An approved organogram is availableRE
SPO
NSIBLE PERSON Ensure that the hospital has an up-to-date, approved and signed organogram for the
hospital. The organogram should be based on the level of the hospital and defined package of services offered.
REVIEWER Verify that the hospital has an up-to-date signed organogram.
There is no checklist for this element
Element 127: Critical management positions in the organogram are filled
RESP
ONS
IBLE PERSON
Ensure that the post for the hospital corporate management services that includes amongst others - Chief Executive Officer; Medical manager, Nursing manager, HR manager, Support Systems manager and Finance and Supply chain manager are available in the organogram and have managers with the appropriate qualifications for their positions.
REVIEWERVerify whether the critical management hospital corporate management services that includes amongst others - Chief Executive Officer; Medical manager, Nursing manager, HR manager, Support Systems manager and Finance and Supply chain manager posts are appropriately filled.
CHECKLIST FOR ELEMENT 127
CRITICAL MANAGEMENT POSITIONS IN THE ORGANOGRAM ARE FILLED
Description Score
Chief Executive Officer
Medical manager
Nursing manager
HR manager,
Support systems manager,
Finance and Supply chain manager
Total score
Maximum possible score
Percentage score %
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Element 128: Critical clinical positions in the organogram are filledRE
SPO
NSIBLE PERSON
The critical clinical position swill be dependent on level of care and package of service offered. At a district hospital, the organogram must include the following clinical positions: Medical officer with Diploma in Child health, Medical officer with Diploma in Obstetrics, Medical Officer with Diploma in Anaesthetics, Family physician, advanced midwife, Pharmacist, and Infection Control Prevention Practitioner.
REVIEWERVerify whether the critical clinical posts for Paediatrics, Anaesthetics, Obstetrics, Family physicians are filled.
CHECKLIST FOR ELEMENT 128
CRITICAL CLINICAL POSITIONS IN THE ORGANOGRAM ARE FILLED
Description Score
Medical officer with Diploma in Child health
Medical officer with Diploma in Obstetrics
Medical Officer with Diploma in Anaesthetics
Family physician
Advanced midwife
Pharmacist
Infection Control Prevention Practitioner
Paediatrician
Obstetrician & Gynaecologist
General Surgeon
Physician
Orthopaedic Surgeon
Anaesthetist
Radiologist
Total score
Maximum possible score
Percentage score %
NB Element 129: Specific support services have designated managers
RESP
ONS
IBLE PERSON Ensure that support services (mortuary, laundry, CSSD, and food services) have suitably qualified designated managers
REVIEWER
Verify that Mortuary, Laundry, CSSD, Food Services have designated managers.
CHECKLIST FOR ELEMENT 129
SPECIFIC SUPPORT SERVICES HAVE DESIGNATED MANAGERS
Description Score
CSSD
Laundry
Food services
Mortuary
Total score
Maximum possible score (sum of all scores minus the ones marked NA)
Percentage score %
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NB Elements 130: Clinical Staffing needs have been determined in line with WISN
RESP
ONS
IBLE PERSON
The hospital executive management in consultation with the district office or provincial office (depending on level of hospital) conduct a WISN assessment. All the information on the staff and clinic services required must be prepared. Use the modified Implementation Guideline of Health Workforce Normative Guides and Standards. Generate a report based on the findings of the WISN assessment to inform staffing needs.
REVIEWER Verify that the clinical staff reflected on the organogram is aligned to the WISN report.
There is no checklist for this element
NB Element 131: Non-clinical staff component is determined according to service needs
RESP
ONS
IBLE PERSON
The hospital executive management, should in consultation with the district office or provincial office (depending on level of hospital), conduct an assessment of the non-clinical staffing needs based on the package of services offered, clinical staffing and hospital catchment population. A report should be generated based on the findings of this assessment.
REVIEWER Verify that the non-clinical staff reflected on the organogram is aligned to the report.
There is no checklist for this element
NB Element 132: All clinical post are filled according to service needs
RESP
ONS
IBLE PERSON
The hospital should fill all clinical posts based on the WISN assessment.
REVIEWER
Check whether all clinical posts according the WISN report have been filled.
CHECKLIST FOR ELEMENT 132
ALL CLINICAL POST ARE FILLED ACCORDING TO SERVICE NEEDS
Description Score
Full time medical officer- level 1
Full time medical officer- level 2
Full time medical officer- level 3
Sessional medical officer- private gp
Community medical officer
Intern
Dentists- full time
Community dental officer
Dentist intern
Dental therapist
Oral hygienist
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CHECKLIST FOR ELEMENT 132
ALL CLINICAL POST ARE FILLED ACCORDING TO SERVICE NEEDS
Description Score
Pharmacist
Pharmacy assistants
Dietician
Physiotherapist
Occupational therapist
Psychologist
Social workers
Optometrist
Professional nurses
Grade 1
Grade 2
Grade 3
Midwife
Mental health nurse
Opthalmic nurse
Clinical associates
Radiographer
Ultrasonographer
Enrolled nurses
Grade 1
Grade 2
Grade 3
Nursing assistants
Grade 1
Grade 2
Grade 3
Paediatrician
Obstetrician & gynaecologist
General surgeon
Physician
Orthopaedic surgeon
Anaesthetist
Radiologist
Total score
Maximum possible score
Percentage score %
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
135
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NB Element 133: All non-clinical post are filled according to service needsRE
SPO
NSIBLE PERSON
The hospital should fill all non-clinical posts based on the service needs assessment.
REVIEWERCheck that all non-clinical posts that have been identified according service needs assessment have been filled.
CHECKLIST FOR ELEMENT 133
ALL NON-CLINICAL POST ARE FILLED ACCORDING TO SERVICE NEEDS
Description Score
Administrative clerks
Grade 1
Grade 2
Grade 3
Data capturers
Grade 1
Grade 2
Grade 3
Lay counsellors
Health promoters
General assistants
Gardener
Porters
Cleaners
Laundry assistants
Mortuary assistants
Drivers
Human resource officers
Finance officers
Procurement officers
Food services
Cssd
Electrician
Boiler maker
Total score
Maximum possible score
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
136
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Element 134: Duty roster for all clinical and non-clinical service areas are available
RESP
ONS
IBLE PERSON
Compile a monthly roster for all clinical and non-clinical service areas.
REVIEWER Verify that there is a duty roster for all clinical and non-clinical service areas.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
137
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Component 5: Human Resources for Health
Sub-component 16: Human Resources Development
COMMITMENT FOR SUB-COMPONENT 16: Monitor whether staff receive development training
Human Resource Management
ELE
ME
NTS
NB 135 Planned in-service training is conducted
NB 136 Planned continuous professional development (CPD) is conducted
137 All staff have received in-service training in the last two years on infection control standard precautions that is in-line with the SOP
138 Staff are trained on the use of equipment necessary for performance of their duties
Vital Essential NB Important
NB Element 135: Planned in-service training is conducted
RESP
ONS
IBLE PERSON
Provide In-service training to all staff on all hospital policies and guidelines, and all SOP relevant to each category of staff.
REVIEWERVerify that there is a schedule of planned in-service training. Check the registers of all such trainings that have taken place in the previous 12 months.
CHECKLIST FOR ELEMENT 135
PLANNED IN-SERVICE TRAINING IS CONDUCTED
Topics included Score
Leadership
Disaster management
Outbreak management
Workplace skills development
Total Score
Maximum possible score
Percentage score %
Who is responsible for this sub-component?
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
138
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NB Element 136: Planned continuous professional development (CPD) is
conducted
RESP
ONS
IBLE PERSON Continuous professional development is an important component for all healthcare workers to maintain their registration with the relevant statutory bodies. The hospital should offer continuous professional development activities to support their staff in maintaining their registration.
REVIEWERCheck that there is a schedule of planned continuous professional development training for all categories of healthcare workers. The registers of all such trainings that have taken place in the previous 12 months.
There is no checklist for this element
Element 137: All staff have received in-service training in the last two years on infection control standard precautions that is in-line with the SOP
RESP
ONS
IBLE PERSON
All clinical and non-clinical staff must receive in-service training on infection control standard precautions.
REVIEWER
Check that there is a schedule of planned in-service training on infection control standard precautions for all staff. Randomly select five clinical and five non-clinical staff and check the registers of all such trainings that have taken place in the previous 24 months. Verify whether staff have received training on all areas listed in checklist 137.
There is no checklist for this element
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
139
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Element 138: Staff are trained on the use of equipment necessary for performance of their duties
RESP
ONS
IBLE PERSON
All staff must receive training on how to use equipment that is required for them to perform their daily duties.
REVIEWERcheck that there is a schedule of training on the use of equipment for each clinical and non-clinical area and registers of such training in the previous 12 months.
CHECKLIST FOR ELEMENT 137
ALL STAFF HAVE RECEIVED IN-SERVICE TRAINING IN THE LAST TWO YEARS ON INFECTION CONTROL STANDARD PRECAUTIONS THAT IS IN-LINE WITH THE SOP
Topics included in training
Sco
re
Clin
ical
1
Clin
ical
2
Clin
ical
3
Clin
ical
4
Clin
ical
5
No
n C
linic
al 1
No
n C
linic
al 2
No
n C
linic
al 3
No
n C
linic
al 4
No
n C
linic
al 5
Healthcare professionals received training on:
· Hand washing and hand hygiene
· Personal Protective Equipment
· Prevention of respiratory infections
· Safe injection practises
· Sharps safety
· Waste management and disposal
· Environmental cleanliness
· Patient Care equipment
· Handling of linen
· Wound care
Total Score
Maximum possible score
Percentage score %
CHECKLIST FOR ELEMENT 137B
ALL STAFF HAVE RECEIVED IN-SERVICE TRAINING IN THE LAST TWO YEARS ON INFECTION CONTROL STANDARD PRECAUTIONS THAT IS IN-LINE WITH THE SOP
Cle
aner
1
Cle
aner
2
Cle
aner
3
Cle
aner
4
Cle
aner
5
Cleaners received training on: - - - - -
· Hand washing and hand hygiene - - - - -
· Personal Protective Equipment - - - - -
· Prevention of respiratory infections - - - - -
· Waste management and disposal - - - - -
· Environmental cleanliness - - - - -
· Handling of linen - - - - -
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Component 5: Human Resources for Health
Sub-component 17: Human Resources Management
COMMITMENT FOR SUB-COMPONENT 17: Monitor the conformance with relevant human resources legislations and policies
Human Resource Management
ELE
ME
NTS
139 All healthcare workers have current registration with relevant professional bodies
140 Non clinical staff have appropriate registration if applicable
141 All relevant human resource management legislation, policies and procedures available
NB 142 Staff members demonstrate that incoming policies and notices have been read
NB 143 All employees details are recorded on PERSAL
NB 144 Record of staff induction is available
NB 145 There is an individual Performance Management Agreement for each staff member
NB 146 Continued staff development needs are determined for the current financial year and submitted to the HR manager
NB 147 An annual leave schedule is available
NB 148 Staff satisfaction survey is conducted annually
NB 149 Exit interviews are conducted for all staff that exit the hospital
NB 150 Occupational Health and Safety annual audit conducted
151 Occupational Health and Safety incidents are managed and recorded in a register
NB 152 Quality improvement plans for human resource management are implemented
NB 153 Functional employee wellness programme (EWP) in place
NB 154 Medical surveillance for all employees is conducted
Vital Essential NB Important
Who is responsible for this sub-component?
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
141
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Element 139: All healthcare workers have current registration with relevant professional bodies
RESP
ONS
IBLE PERSON On an annual basis, all healthcare professionals must renew their registration with the relevant professional bodies. The human resource department should keep a copy of the registration certificate on file.
REVIEWERVerify that all health professionals have current registration with the relevant professional bodies.
CHECKLIST FOR ELEMENT 139
ALL HEALTHCARE WORKERS HAVE CURRENT REGISTRATION WITH RELEVANT PROFESSIONAL BODIES
Score
Family physician
Full time medical officer-
Sessional medical officer- private gp
Community medical officer
Intern
Dentists- full time
Community dental officer
Dentist intern
Dental therapist
Oral hygienist
Pharmacist
Pharmacy assistants
Dietician
Physiotherapist
Occupational therapist
Psychologist
Social workers
Optometrist
Professional nurses
Clinical associates
Radiographer
Ultrasonographer
Enrolled nurses
Nursing assistants
Paediatrician
Obstetrician & gynaecologist
General surgeon
Physician
Orthopaedic surgeon
Anaesthetist
Radiologist
Score
Maximum possible score
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
142
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Element 140: Non-clinical staff have appropriate registration if applicable
RESP
ONS
IBLE PERSON Ensure that non-clinical staff such as electricians, boilermakers, plumbers and water engineers are certified and have registration with the relevant professional bodies. The human resource department should keep a copy of the registration certificate on file.
REVIEWERVerify that all non-clinical staff have certification/registration with the relevant professional bodies.
CHECKLIST FOR ELEMENT 140
NON CLINICAL STAFF HAVE APPROPRIATE REGISTRATION IF APPLICABLE
Score
Electrician
Boiler makers
Plumbers
Water engineers
Score
Maximum possible score
Percentage score
Element 141: All relevant human resource management legislation, policies and procedures available
RESP
ONS
IBLE PERSON Ensure that all human resource policies, procedures and legislation are available at the facility and accessible for every staff member. Download the relevant policies from www.labour.gov.za and www.dpsa.gov.za
REVIEWER
Verify that all the policies are available at the facility and accessible for staff members.
CHECKLIST FOR ELEMENT 141
ALL RELEVANT HUMAN RESOURCE MANAGEMENT LEGISLATION, POLICIES AND PROCEDURES AVAILABLE
Score
Basic Conditions of Employment
Occupational Health and Safety Act
Labour Relation Act
Leave Policy
Disciplinary Process
Injury on Duty
Recruitment and retention policy
Management of absenteeism
RWOP
Score
Maximum possible score
Percentage score %
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
143
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NB Element 142: Staff members demonstrate that incoming policies and
notices have been readRE
SPO
NSIBLE PERSON
Discuss the new policies and notices that are received with staff immediately. Ensure that the relevant staff members understand the changes and determine if further training may be required. If training is required, request this using the district training protocol. Staff members that must implement and/or have knowledge of the policies/guidelines and notices must sign the acknowledgement form for the specific policies/guidelines and notices. Attach this to the back of the new policy/guidelines or notice and file the document.
REVIEWERRequest the human resources official to explain the process for dissemination new policies or notices to staff. Ask to see proof that staff have read and understood the policy.
There is no checklist for this element
NB Element 143: All employees’ details are recorded on PERSAL
RESP
ONS
IBLE PERSON PERSAL is the database for all human resources in the public sector. Ensure that all employee’s details must be entered on PERSAL soon after employment.
REVIEWER
Interview the human resource officer and ask if PERSAL is updated. Assess a sample of employees to determine whether the system is updated.
There is no checklist for this element
NB Element 144: Record of staff induction is available
RESP
ONS
IBLE PERSON
All newly appointed staff. Staff should receive induction training within the first three months of being appointment. The training must cover at a minimum the following:
• Vision and mission of the hospital
• Batho Pele Principles; Patients Right Charter
• Operational policies and procedures
• Health and Safety of patients and staff (non-clinical risk)
• Quality improvement methodology
• Infection Prevention and Control
• Patient safety (clinical risk)
Keep attendance registers of the training conducted.
REVIEWERVerify which staff members have been appointed in the past 12 months. Check on the training register whether these staff members have received induction training.
There is no checklist for this element
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
144
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NB Element 145: There is an individual Performance Management
Agreement for each staff member
RESP
ONS
IBLE PERSON
Staff members in consultation with their line manager must sign a performance management agreement.
REVIEWER Randomly select 5 clinical and non-clinical staff members and verify whether the performance agreement is up to date; line manager is identified and the assessment is conducted bi-annually (Checklist 145).
CHECKLIST FOR ELEMENT 145
THERE IS AN INDIVIDUAL PERFORMANCE MANAGEMENT AGREEMENT FOR EACH STAFF MEMBER
Clinical Non-clinical
SCO
RE
Staff
m
emb
er 1
Staff
m
emb
er 2
Staff
m
emb
er 3
Staff
m
emb
er 4
Staff
m
emb
er 5
Staff
m
emb
er 6
Staff
m
emb
er 7
Staff
m
emb
er 8
Staff
m
emb
er 9
Staff
m
emb
er 1
0
Performance agreement is up-to-date
Line manager identified
Performance agreement to be assessed bi-annually
Score
Maximum possible score
Percentage score %
NB Element 146: Continued staff development needs are determined
for the current financial year and submitted to the HR manager
RESP
ONS
IBLE PERSON Each line manager should identify their staff development needs based on the performance management agreements. Submit a list of the development to the HR manager. The HR manager should collate these lists and plan staf developmental training appropriately.
REVIEWER Request to see that the HR manager has developed a list of staff developmental needs.
There is no checklist for this element
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
145
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NB Element 147: An annual leave schedule is available
RESP
ONS
IBLE PERSON Each line manager must draw up an annual leave schedule for their staff, taking into account service needs. This list must be printed and be available on the staff notice board or in a file.
REVIEWER check that each clinical and non-clinical department has an annual leave schedule.
There is no checklist for this element
NB Element 148: Staff satisfaction survey is conducted annually
RESP
ONS
IBLE PERSON
The hospital must in conjunction with the district/provincial office, conduct an annual staff satisfaction survey. Quality assurance and the human resource unit must analyse the results and present to hospital executive management and DHMT with recommendations for improvement. An action plan to address relevant weaknesses highlighted in the staff satisfaction survey report must be developed.
REVIEWER
Request the report of staff satisfaction survey conducted in the previous 12 months and that the action plan is being implemented.
There is no checklist for this element
NB Element 149: Exit interviews are conducted for all staff that exit the
hospital
RESP
ONS
IBLE PERSON
The HR department must offer any staff member that is terminating their employment with the hospital na opportunity to complete an exit interview. This can be done electronically or on a hard copy. The human resource unit must analyse the results and present to hospital executive management with recommendations for improving staff retention.
REVIEWERRequest to see reports of exit interviews conducted in the previous 12 months and that an action plan has been developed to improve staff retention.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
146
Draf
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NB Element 150: Occupational Health and Safety annual audit conducted
RESP
ONS
IBLE PERSON The hospital must conduct an annual OHS audit. The results of the audit must be presented to the hospital executive management with action plans to manage any risks identified.
REVIEWERRequest to see reports of OHS audit conducted in the previous 12 months and that the action plan is being implemented.
There is no checklist for this element
Element 151: Occupational Health and Safety incidents are managed and recorded in a register
RESP
ONS
IBLE PERSON
All occupational health and safety incidents must be reported by completing the WCL1 or WCL 2 forms for all staff that was involved in an occupational health and safety incident. These forms should be submitted to the Province or District human resources unit. All the occupational health and safety incidents must be recorded in a register, together with the actions taken to manage the incident.
REVIEWER
Verify that the OHS incident register is completed accurately and includes the action plan for each incident.
There is no checklist for this element
NB Element 152: Quality improvement plans for human resource
management are implemented
RESP
ONS
IBLE PERSON
The HR manager must develop a QIP based on the results of the staff satisfaction survey, exit interviews, occupational health and safety audits and any other audits/surveys conducted amongst staff. These reports should contain a baseline analysis, identification of deficiencies, root cause analysis, implementation of intervention and evaluation of the intervention.
REVIEWERrequest documentation pertaining to all quality improvement initiatives. These reports should contain a baseline analysis, identification of deficiencies, root cause analysis, implementation of intervention and evaluation of the intervention.
There is no checklist for this element
NB Element 153: Functional employee wellness programme (EWP) in
place
RESP
ONS
IBLE PERSON
The HR manage is responsible for the implementation of an EWP for all staff. The EWP must be aligned to the Employee Health and Wellness Strategic Framework for the Public Service. The EWP must include the 4 priority areas: (i) HIV&AIDS, STI and TB Management; (ii) Health and Productivity Management; (iii) Safety, Health, Environment, Risk and Quality Management (SHERQ); and (iv) Wellness Management.
REVIEWER Request for documentation of EWP activities conducted in the previous 12 months.
There is no checklist for this element
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
147
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NB Element 154 Medical surveillance for all employees is conducted
RESP
ONS
IBLE PERSON All employees must undergo a baseline clinical examination at the time of employment. The initial assessment may include biological monitoring. In addition, regular follow-up examinations and biological monitoring must be arranged accordingly.
REVIEWER Check medical surveillance records to establish whether pre-placement medical examination are conducted; immunizations are offered and regular examinations are conducted on healthcare workers.
CHECKLIST FOR ELEMENT 154
MEDICAL SURVEILLANCE FOR ALL EMPLOYEES IS CONDUCTED
Description Score
Pre-placement examination performed
Healthcare workers are offered relevant immunisations
Regular medical examination for all healthcare workers
Score
Maximum possible score
Percentage score %
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
148
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Component 6: Support Services
Sub-component 18: Hygiene and cleanliness
COMMITMENT FOR SUB-COMPONENT 18: Monitor whether the required procedures and resources are available to ensure
Shared across all service areas, patient support services and hospital corporate services
ELE
ME
NTS
155 Exterior of the hospital is clean and tidy
156 All cleaners are trained on cleaning protocols and procedures
NB 157 Cleaning schedules are available
NB 158 All work completed is signed off by cleaners and verified by manager or delegated staff member
159 Clinical Service areas are clean
160 Support service areas are clean
161 Clean running water, toilet paper, liquid hand wash soap and disposable hand paper towels are available
162 Toilets are clean, intact and functional in all service areas
163 Bathrooms are clean, intact and functional in all service areas
164 Portable warning signs indicating wet areas are used
165 Disinfectant, cleaning materials and equipment are available
Vital Essential NB Important
Who is responsible for this sub-component?
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
149
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Element 155: Exterior of the hospital is clean and tidyRE
SPO
NSIBLE PERSON The systems manager is responsible for ensuring that the exterior of the hospital is
clean and tidy. Ensure that the facility is free of litter, the corridors, external walls and windows are clean. Use in-house services or external service providers to neaten the flower beds and cut the grass
REVIEWER Observe whether the exterior of the facility is free from dirt and litter; walls and corridors are clean; grass is cut; paving and flower beds are free from weeds (Checklist 155)
CHECKLIST FOR ELEMENT 155
EXTERIOR OF THE HOSPITAL IS CLEAN AND TIDY
Description Score
The facility’s premises are clean(e.g. free from dirt and litter)
Exterior walls of the facility are clean
Corridors are clean
Grass is cut
Paving is free of weeds
Flower beds are well kept and free of weeds
Total score
Total maximum possible score
Percentage score %
Element 156: All cleaners are trained on cleaning protocols and procedures
RESP
ONS
IBLE PERSON
Appropriately train the cleaners and ensure that they are fully aware of their duties. If the facility has contract cleaners, meet with the contractor, ensure that the cleaners in your facility have been trained, and have a clear understanding of their duties. Identify and record additional training needs of cleaners. Maintain records of training of each cleaner.
REVIEWERRequest to see the training schedule for cleaners and interview a few trainers to establish if they are trained.
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
150
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NB Element 157: Cleaning schedules are available
RESP
ONS
IBLE PERSON
Compile daily, weekly and monthly cleaning schedules for all areas in the facility. Keep a copy of the schedules in the cleanliness file.
REVIEWER
Request to see the cleaning schedule for each service area.
NB Element 158: All work completed is signed off by cleaners and
verified by manager or delegated staff member
RESP
ONS
IBLE PERSONEnsure that cleaning is in line with expected standards and that cleaners take responsibility for their allocated areas through appropriate supervision and sign-off on check lists for toilets. The manager or the professional health care staff member delegated by the manager to supervise the cleanliness of areas must also sign the checklist schedule and indicate on the schedule whether he/she is satisfied with the cleanliness of the areas. File the checklist in the cleanliness file and should be used to guide performance evaluation of cleaners.
REVIEWERRequest to see the cleanliness file and the signed off work schedule forms in terms of cleanliness of the specific area listed below.
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
151
Draf
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Element 159: Clinical Service areas are cleanRE
SPO
NSIBLE PERSON Ensure that the windows, walls, floors, mirrors, doors are clean in all clinical areas. The
cleanliness in these areas is in line with expected standards and that cleaners take responsibility for their allocated areas. Bins must not be overflowing and the area must be odour free.
REVIEWERReview: Conduct a walk through the facility and observe whether the windows, windowsills, floor; countertops; door handles and mirrors are clean.
CHECKLIST FOR ELEMENT 159
CLINICAL SERVICE AREAS ARE CLEAN
Description Score
Windows clean
Window sills clean
Floor is clean
Wall skirting are free of dust
The countertops are clean
The door handles are clean
Mirrors are clean
Walls are clean
Bins are not over flowing
Bins are clean
The areas are odour-free
All areas free of cobwebs
Waiting areas are clean
Staff rooms are clean
Score
Maximum possible score
Percentage score %
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
152
Draf
t (ne
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Element 160: Support service area are clean
RESP
ONS
IBLE PERSON Ensure that the windows, walls, floors, mirrors, doors are clean in all support service areas. The cleanliness in these areas is in line with expected standards and that cleaners take responsibility for their allocated areas. Bins must not be overflowing and the area must be odour free.
REVIEWER Review: Conduct a walk through the facility and observe whether the windows, windowsills, floor; countertops; door handles and mirrors are clean in all support service areas (Checklist 160).
CHECKLIST FOR ELEMENT 160
SUPPORT SERVICE AREAS ARE CLEAN
Description Score
Windows clean
Window sills clean
Floor is clean
Wall skirting are free of dust
The countertops are clean
The door handles are clean
Mirrors are clean
Walls are clean
Bins are not over flowing
Bins are clean
The areas are odour-free
All areas free of cobwebs
Waiting areas are clean
Staff rooms are clean
Score
Maximum possible score
Percentage score %
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
153
Draf
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Element 161: Clean running water, toilet paper, liquid hand wash soap and disposable hand paper towels are available
RESP
ONS
IBLE PERSON
Ensure that all toilets across all clinical and service areas have clean running water, toilet paper, liquid hand wash soap and disposable hand paper towels. In addition all consultation rooms should have liquid hand wash soap and disposable hand paper towels
REVIEWER Conduct a walk through the facility and observe whether all clinical and support service areas clean running water, toilet paper, liquid hand wash soap and disposable hand paper towels. Assess whether there is should have liquid hand wash soap and disposable hand paper towels all consultation rooms and vital signs rooms.
CHECKLIST FOR ELEMENT 161
CLEAN RUNNING WATER, TOILET PAPER, LIQUID HAND WASH SOAP AND DISPOSABLE HAND PAPER TOWELS ARE AVAILABLE
Item Score
Toilet
Running water
Toilet paper
Liquid hand wash soap
Disposable hand paper towels
Consultation room
Liquid hand wash soap
Disposable hand paper towels
Vital signs room
Liquid hand wash soap
Disposable hand paper towels
Score
Maximum possible score
Total score for all areas
Total maximum possible score
Percentage score %
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 162: Toilets are clean, intact and functional in all service areasRE
SPO
NSIBLE PERSON
Ensure that the windows, walls, floors, urinals are clean in all toilets. The cleanliness in these areas is in line with expected standards and that cleaners take responsibility for their allocated areas. Sanitary bins must not be overflowing and the area must be odour free. The toilet bowel cover must be intact and the seat stain free. The flush mechanism must be operational.
REVIEWERConduct a spot check for the toilets in all clinical and service areas and check whether the windows, walls, floors, urinals are clean in all toilets. Sanitary bins must not be overflowing and the area must be odour free. The toilet bowel cover must be intact and the seat stain free. The flush mechanism must be operational.
CHECKLIST FOR ELEMENT 162
TOILETS ARE CLEAN, INTACT AND FUNCTIONAL IN ALL SERVICE AREAS
ITEM Score
Cleanliness of toilets
Windows clean
Window sills clean
Floor is clean
Basins are clean
Walls are clean
Toilets/urinals are clean
Sanitary bins clean and not overflowing
The areas are odour-free
All areas free of cobwebs
Intact and functional
The toilet bowl seat and cover/squat pan is intact
The toilet bowl is stain free
The toilet flush/sensor flush is functional
The toilet cistern cover is complete and in place
The urinals are intact and functional
The urinal/flush sensor is functional
Score
Maximum possible score
Total score for all 3 toilets
Total maximum possible score
Percentage score %
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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Element 163: Bathrooms are clean, intact and functional in all service areas
RESP
ONS
IBLE PERSON
Ensure that the windows, walls, floors, urinals are clean in all bathrooms. The cleanliness in these areas is in line with expected standards and that cleaners take responsibility for their allocated areas. Sanitary bins must not be overflowing and the area must be odour free. The bath/shower cubicle must be intact and stain free. The taps must be intact and the drains free flowing.
REVIEWERConduct a spot check for the bathrooms in all clinical and service areas and check whether the windows, walls, floors, urinals are clean in bathrooms in all service areas.
CHECKLIST FOR ELEMENT 163
BATHROOMS ARE CLEAN, INTACT AND FUNCTIONAL IN ALL SERVICE AREAS
ITEM
Cleanliness of bathrooms Score
Windows clean
Window sills clean
Floor is clean
Basins are clean
Walls are clean
Toilets/urinals are clean
Sanitary bins clean and not overflowing
The areas are odour-free
All areas free of cobwebs
Intact and functional
The bathtub/shower cubicle is intact
The bathtub/shower cubicle is stain free
The taps are functional
The bathtub/shower drain is free flowing
Score
Maximum possible score
Total score for all 3 toilets
Total maximum possible score
Percentage score %
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 164: Portable warning signs indicating wet areas are usedRE
SPO
NSIBLE PERSON
South African regulations made under the Occupational Health and Safety Act, 1993 as well as by-laws require employers to provide and maintain safety signs where there is significant risk to health and safety. Crucial in any work environment, the purpose is to prevent injury and ensure staff and visitors are well aware of the possible dangers and hazards ahead in certain situations and/or environments.
Wet floor signs are used to notify and/or remind people of slip and fall hazards in the immediate area. These hazards include the presence of liquid or other slippery substance on the walking surface as a result of routine cleaning, accidental spills, product leaks, or presence of inclement weather conditions.
REVIEWER Observe whether during the cleaning process of any clinical or service areas these warning signs are displayed until the area is dry.
Element 165: Disinfectant, cleaning materials and equipment are available
RESP
ONS
IBLE PERSON
Obtain the National Ideal Clinic Health Commodities Specification Catalogue that contains specifications for cleaning equipment from www.health.gov.za. Verify that the facility has the prescribed list of non-negotiable disinfectant, cleaning materials and equipment. and ensure that facility has disinfectant, cleaning materials and equipment at all times.
Obtain material safety data sheets for all cleaning material used in the facility.
REVIEWERConduct a spot check to assess if the disinfectant, cleaning materials and equipment is available at the facility.
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapyNutritional support (dietetics)Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prostheticsRehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive managementAdministration/reception servicesSystems managementSupply chain managementFinancial managementHuman resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapyNutritional support (dietetics)Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prostheticsRehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive managementAdministration/reception servicesSystems managementSupply chain managementFinancial managementHuman resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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CHECKLIST FOR ELEMENT 165
DISINFECTANT, CLEANING MATERIALS AND EQUIPMENT ARE AVAILABLE
Description Score
High level disinfection for medical equipment (e.g Sodium Perborate PowderOR Phthalaldehyde)
Chlorine compounds (e.g Biocide D or Clorox)
Sanitary all- purpose cleaner
Detergent-based solutions
Wet polymer (floor polish)
Protective polymer(strippers)
All cleaning materials clearly labelled
Materials Safety Data Sheets for all cleaning products
Cleaning equipment
Two way bucket system for mopping floors (bucket for clean water and bucket for dirty water) OR Janitor trolley
Colour labelled mop – Red for toilets and bathrooms
Colour labelled mop – Blue for clinical areas and non-clinical service areas
Mop labelled for cleaning exterior areas
Green bucket and cloths for bathroom and consulting room basins
Red bucket and cloths for toilet
Yellow bucket and cloth for biohazardous waste (blood and body fluid spills)
White cloths for kitchen
Blue bucket and cloths for clinical areas and non-clinical service areas
Spray bottle for disinfectant solution
Window cleaning squeegee
Mop sweeper or soft-platform broom
Floor polisher
Total score
Total maximum possible score
Percentage score %
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Component 6: Support services
Sub-component 19: Healthcare waste management
COMMITMENT FOR SUB-COMPONENT 19: Monitor whether the required procedures for healthcare waste management are available and appropriately utilised
Systems Management
ELE
ME
NTS
NB 166 SOP for managing general and health care risk waste is available
167 Health care waste is managed appropriately in all service areas
168 Storage area for health care waste is appropriate
169 A signed healthcare risk waste removal service level agreement between the health department and the service provider is available
170 Healthcare risk waste is removed in line with the contract
171 Register for all anatomical waste disposal is completed
Vital Essential NB Important
NB Element 166: SOP for managing general and health care risk waste is
available
RESP
ONS
IBLE PERSON Ensure that the facility has a SOP for managing general and healthcare risk waste is available. The SOP mujst be in conformance with the Regulations issued by the Department of Health.
REVIEWERReview: Request to see a copy of the SOP for managing general and healthcare risk waste.
There is no checklist for this element
Who is responsible for this sub-component?
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Element 167: Health care waste is managed appropriately in all service areas
RESP
ONS
IBLE PERSON
Display on notice board in all service areas the instructions for the correct use of coloured bin liners to be used for sanitary disposal and general waste management.
• Medical waste disposal bins//boxes must be lined with red plastic
• General bins and sanitary disposal bins/boxes must be lined with the appropriate coloured bin liners
• All disposal bins/boxes must be clean and intact
• Broken disposal bins/boxes must be replaced with new ones
Place the sanitary, health care risk waste and general disposal bins in the appropriate areas. Disposal bins/boxed must never be more than three quarters full and disposal bins/boxes must be emptied as needed.
REVIEWERUse checklist 167 to ascertain whether healthcare risk is appropriately managed in all service areas.
CHECKLIST FOR ELEMENT 167
HEALTH CARE WASTE IS MANAGED APPROPRIATELY IN ALL SERVICE AREAS
Score
Sanitary disposal bins with functional lids OR health care risk waste box
Sanitary disposal bins/boxes lined with appropriate colour plastic bags
Sanitary disposal bins/boxes are clean and not overflowing
Health care risk waste disposal bins with functional lids OR health care risk waste box
Health care waste disposal bins/boxes lined with red colour plastic bags
Health care waste disposal bins/boxes contain only health care waste
Health care waste disposal bins/boxes are not overflowing
Bins available for general waste
Bins for general waste are lined with appropriate coloured bags
Total score
Total maximum possible score
Percentage score %
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
CHECK IN THESE
FUNCTIONAL AREAS
SECTION 8 IDEAL HOSPITAL REALISATION AND MAINTENANCE FRAMEWORK
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Element 168: Storage area for health care waste is appropriate
RESP
ONS
IBLE PERSON Clearly demarcate storage area for general and healthcare risk. The healthcare risk management area must be accessed control, clean and rodent free, well ventilated and have adequate drainage.
REVIEWER
Use checklist 168 and assess whether storage for healthcare risk is appropriate.
CHECKLIST FOR ELEMENT 168
STORAGE AREA FOR HEALTH CARE WASTE IS APPROPRIATE
General waste storage area ScoreGeneral waste is stored in a designated area General waste is stored in appropriate containers which are neatly packed or stacked
Healthcare risk waste storage area
Healthcare risk waste is stored in an access-controlled area
Health care waste storage area is clean and free from rodents
Healthcare storage area is well ventilated
Healthcare risk waste containers must be stored on shelves
Area has access to water to hose the area
Area has adequate drainage for the water
Total score
Total maximum possible score
Percentage score %
Element 169: A signed healthcare risk waste removal service level agreement between the health department and the service provider is available
RESP
ONS
IBLE PERSON
Ensure that there is a signed healthcare risk waste removal service level agreement between the health department and a reliable service provider.
REVIEWERRequest a copy of the signed healthcare risk waste removal service level agreement between the health department and a service provider.
There is no checklist for this element
SECTION 8IDEAL HOSPITAL COMPONENTS, SUB-COMPONENTS AND ELEMENTS
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Element 170: Healthcare risk waste is removed in line with the contract
RESP
ONS
IBLE PERSON The service level agreement between the health department and the service provider should stipulate frequency of healthcare risk removal. The healthcare risk must be weighed and an appropriate record must be kept at the facility.
REVIEWERRequest to see records of healthcare risk being removed and assess whether this is in line with the contract.
There is no checklist for this element
Element 171: Register for all anatomical waste disposal is completed
RESP
ONS
IBLE PERSON
Records of all anatomical waste disposed must be available. The records must include name of patient, date of placement and disposal.
REVIEWERRequest to see register for anatomical waste disposed. The register must contain include name of patient, date of placement and date of disposal (Checklist 171)
CHECKLIST FOR ELEMENT 171
REGISTER FOR ALL ANATOMICAL WASTE DISPOSAL IS COMPLETED
Patient identification
Date of placement
Date of removal
Total score
Total maximum possible score
Percentage score %
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Component 6: Support services
Sub-component 20: Centralised sterilization Services and distribution:
COMMITMENT FOR SUB-COMPONENT 20: Monitor whether the procedures are in place and appropriately applied for the decontamination and sterilisation of medical instruments
Patient support services – Centralised sterilisation services and distribution
ELE
ME
NT
NB 172 SOP for the decontamination and sterilisation of surgical and obstetric instruments is available
NB 173 Process for the decontamination and sterilisation of surgical and obstetric instruments is adhered to
NB 174 All sterilisation equipment is validated / licensed
NB 175 Planned maintenance of sterlisation equipment is according to the schedule
176 Sterile surgical packs are available
177 Sterile obstetric packs are available
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 172: SOP for the decontamination and sterilisation of
surgical and obstetric instruments is availableRE
SPO
NSIBLE PERSON
Ensure that the facility has a SOP for decontamination and sterilisation of surgical and obstetric instruments
The SOP must cover at a minimum:
• Decontamination of reusable devices and surgical instruments
• Procedures on single use device
• Handling of potentially infectious instruments and materials.
• Hazardous chemicals and their use
• Procedures of packing and assembly of instruments
• Testing and use of equipment for disinfecting
• Tracking system for product sterilization, identification, recording and recalls
• Safe handling of used instruments, including their checking and transport to CSSD
• When to perform manual cleaning
REVIEWERRequest to see a copy of the SOP for and sterilisation of surgical and obstetric instruments.
There is no checklist for this element
NB Element 173: Process for the decontamination and sterilisation of
surgical and obstetric instruments is adhered to
RESP
ONS
IBLE PERSON Surgical and obstetric instruments must be decontaminated prior to cleaning. There is a separation of areas for decontaminating cleaned and soiled equipment. Assess the success of sterilisation for each cycle using Chemical and biological indicators.
REVIEWERInterview the CSSD manager and understand the process followed for decontamination of surgical and obstetric instruments. Ask questions pertaining to the checklist item.
CHECKLIST FOR ELEMENT 173
PROCESS FOR THE DECONTAMINATION AND STERILISATION OF SURGICAL AND OBSTETRIC INSTRUMENTS IS ADHERED TO
Description Score
Soiled instruments are decontaminated before cleaning
Soiled and cleaned items are processed in separate areas
Items for sterilisation are packaged
Biological and/or chemical indicators are used to monitor the success of sterilisation for every cycle
Total score
Total maximum possible score
Percentage score %
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NB Element 174: All sterilisation equipment is validated / licensed
RESP
ONS
IBLE PERSON
Procure all sterilisation equipment from authorised sellers using the procurement procedures. Ensure that all equipment have appropriate certification.
REVIEWER Request to see validation/licences for all CSSD equipment.
There is no checklist for this element
NB Element 175: Planned maintenance of sterlisation equipment is
according to the schedule
RESP
ONS
IBLE PERSON
Ensure that there is a planned maintenance schedule for all CSSD equipment. These should be in line with manufacturer guidelines.
REVIEWERRequest a copy of the maintenance schedule and register to assess whether planned maintenance is according to the schedule.
There is no checklist for this element
Element 176: Sterile surgical packs are available
RESP
ONS
IBLE PERSON
A standardised list of essential surgical instruments required for surgical procures for the designated level of hospital is required. Ensure that the facility has sufficient surgical packs based on utilisation rate at the facility. Conduct quarterly audits to ensure that the facility has sufficient quantity and quality.
REVIEWER Obtain a sample of surgical packs and audit whether the required instruments are present.
CHECKLIST FOR ELEMENT 176
STERILE SURGICAL PACKS ARE AVAILABLE
Description Quantity Score
Small stitch tray 1
Stitch scissor 1
Toothed Forcep 1
Non – toothed Forcep 1
Bard- Parkersurgical blade handle to fit accompanying blades (blades do not form part of sterilised pack but must be available) 1
Mosquito straight 2
Mosquito curved 2
Artery forceps straight 2
Artery forceps curved 2
Needle holder 1
Swab holder 1
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CHECKLIST FOR ELEMENT 176
STERILE SURGICAL PACKS ARE AVAILABLE
Description Quantity Score
Vasectomy kit Size
Instrument tray, covered, 22.5 × 12.5 × 5 cm
Towel clips (Backhaus)
Forceps, haemostatic
straight, 14 cm
curved, 12.5 cm
Tissue forceps (Allis), 15 cm
Surgical knife handle, No. 3
Surgical blades, size 10
Hypodermic needles, 22-gauge
Hypodermic needles (Luer), 25-gauge
Needles, suture, straight
Needles, suture, for catgut (Mayo) ½ circle
Scissors, suture, angled on flat, 14 cm
Syringe, anaesthetic (control) (Luer), 5 ml
Syringes, hypodermic, 5 ml
Sterilizer, instrument, 20 × 10 × 6 cm
Forceps (Cheatle), 26.5 cm
Mini-laparotomy kit Size
Tissue forceps (Allis), 19 cm
Towel clips (Backhaus)
Syringe, anaesthetic (control), 10 ml
Hypodermic syringes, 10 ml
20-gauge hypodermic needles, 4 cm
Dressing forceps, 14 cm
Tissue forceps, standard, 14 cm
Mosquito forceps, curved, 13 cm
Artery forceps, straight, 15.5 cm
Tissue forceps (Babcock), 19.5 cm
Artery forceps, curved, 20 cm
Dressing forceps, 25 cm size 14
Surgical knife handle, No. 4 size 16
Surgical blades, size 10 size 18
Needle holder (Mayo), 17.5 cm
Straight triangular point suture needles, 5.5 cm
Taper point needles (Mayo), size 6
Urethral catheters (French gauge)
Tenaculum forceps
Uterine elevator (Ramathibodi)
Tubal hook (Ramathibodi)
Proctoscope
Stainless steel sponge bowl
Retractors (Richardson-Eastman)
Abdominal retractor
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CHECKLIST FOR ELEMENT 176
STERILE SURGICAL PACKS ARE AVAILABLE
Description Quantity Score
Vaginal speculum, medium (Graves)
Suture scissors
Operating scissors, straight, 15 cm
Scissors, curved, 17.5 cm
Instrument pan with lock lid
Total score
Percentage Score %
Element 177: Sterile obstetric packs are available
RESP
ONS
IBLE PERSON
A standardised list of essential obstetric instruments required for normal deliveries, episiotomies, and vacuum deliveries, insertion of intra-uterine devices, dilatation and curettage and termination of pregnancy for the designated level of hospital is required. Ensure that the facility has sufficient sterile obstetric packs based on utilisation rate at the facility. Conduct quarterly audits to ensure that the facility has sufficient quantity and quality.
REVIEWERObtain a sample of obstetric packs and audit whether the required instruments are present.
CHECKLIST FOR ELEMENT 177
STERILE OBSTETRIC PACKS ARE AVAILABLE
ITEM QUANTITY SCORE
NON-NEGOTIABLE ITEMS Stitch scissor 1
Episiotomy scissor 1
Cord scissor 1
Dissecting forcep non-toothed (plain) 1
Dissecting forcep toothed 1
Artery forceps straight long 2
Needle holder 1
Small bowl 2
Kidney dishes OR Receivers (big) 2
EXTRAS (not part of sterilised pack) Quantity
Basin 1
Stainless steel round bowl large 1
Green towels 4
Disposable apron 2
Gauzes 5
Vaginal tampons 1
Sanitary Towels 2
Round cotton wool balls 1 pack
Umbilical cord clamps 2
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CHECKLIST FOR ELEMENT 177
STERILE OBSTETRIC PACKS ARE AVAILABLE
ITEM QUANTITY SCORE
Instruments for vacuum extraction or forceps delivery (including instruments for episiotomy and repair*) Quantity
Vacuum extractor (Malmstrom) 1
Obstetric outlet forceps (Wrigley) 1
Obstetric forceps, midcavity (Neville Barnes) 1
Obstetric forceps, breech delivery (Piper) 1
*Sponge forceps 1
*Artery forceps (Spencer Wells) large
*Artery forceps (Spencer Wells) large 1
*Needle holder x 1 1
*Stitch scissors x 1 1
*Episiotomy scissors x 4 4
*Dissecting forceps, toothed 1
*Dissecting forceps, non-toothed 2
Urethral catheter, rubber or latex 2
Urethral catheters (Foley) gauges 12-21 1
Towel clips 1
Vaginal speculum, large (Sims) 1
Vaginal speculum (Hamilton Bailey) 1
Kidney dish 1
Gallipot 1
DILATATION AND CURETTAGE SET Dilators
Dilators sizes 3/4 1
Dilators sizes 5/6 1
Dilators sizes7/8 1
Dilators sizes 9/10 1
Dilators sizes 11/12 1
Dilators sizes 13/14 1
Dilators sizes 15/16 1
Forceps
Ramples 4
Vulsellum 2
Polypi 2
Cervix holding 2
Rotunder/ urine catheter 1
Sound 1
Curettes sizes
Curettes sizes 1 1
Curettes sizes 2 1
Curettes sizes 3 1
Curettes sizes 4 1
Curettes sizes 5 1
Curettes sizes 6 1
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CHECKLIST FOR ELEMENT 177
STERILE OBSTETRIC PACKS ARE AVAILABLE
ITEM QUANTITY SCORE
Curettes sizes 7 1
Jug 1
Retractors 1
Auvard 1
Sims 1
TERMINATION OF PREGNANCY SET
Medium bowl with gauze
Big receiver 1
Vusselum clamp 1
Short sponge
Steri- paper
Sterile hand paper towel 2
CAESAREAN SECTION SET
Dissecting forceps/ tissue holding
Forceps Quantity (Minimum per set)
1 ramsey toothed 1
1 bonney toothed 1
1 gillies forceps 1
1 mc indoe plain 1
1 russian forceps 1
2 lanes forceps 2
2 allis forceps 2
2 babcock forceps 2
Artery forceps
5 spencer wells (curved) 5
5 spencer wells (straight) 5
5 criles/mosquitoes curved/straight 5
knockers 2
Retractors
1 doyens retractor 1
2 czerneys 2
1 morrison 1
5 green armitages (for holding the uterus) 5
2 roberts 2
2 size 4 2
Bp handles
1 size 3 1
1 size 5/7 1
Scissors
2 mayo curved scissors 2
2 straight scissors 2
1metzenbaum 1
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CHECKLIST FOR ELEMENT 177
STERILE OBSTETRIC PACKS ARE AVAILABLE
ITEM QUANTITY SCORE
Needle holders
2 needle holders 2
1 diathermy knife 1
1 wriggles forceps 1
1 cheatle forceps 1
1 pool’s suction 1
1 suction tubing 1
ramples 5
receiver for the placenta 1
Total score
Total maximum possible score
Percentage score %
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Component 6: Support services
Sub-component 21: Security
COMMITMENT FOR SUB-COMPONENT 21: Monitor whether systems processes, procedures are in place to protect the safety of assets, infrastructure, patients and staff of the hospital
Systems manager
ELE
ME
NTS
NB 178 There is a standard operating procedure for safety and security for staff and patients
NB 179 There is a signed Service Level agreement in accordance with the SOP with the outsourced service provider
NB 180 Perimeter fencing is intact
NB 181 Secure Parking for staff is provided
NB 182 There is a standard security guard room at the entrances of the hospital
NB 183 There are security guards on duty at all times
NB 184 Security breaches are managed and recorded in a register
185 There is access control to specified areas
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 178: There is a standard operating procedure for safety and
security for staff and patientsRE
SPO
NSIBLE PERSON
Ensure that the facility has a safety and security SOP for staff and patients. The SOP must cover at a minimum the following:
• High risk areas and the specific security needs for these areas
• Access control within the facility
• Reporting of security incidents (see register for security breaches)
• Training of personnel on the management of alarms (where applicable), provision of guarding services and patrolling
• Equipment for personnel
• Maintenance and replacement of security equipment
REVIEWER Request to see a copy of the SOP for safety and security for staff and patients.
There is no checklist for this element
NB Element 179: There is a signed Service Level agreement in
accordance with the SOP with the outsourced service provider
RESP
ONS
IBLE PERSON Establish a service agreement with a reliable security guarding service in accordance with procurement guidelines. The service level agreement must stipulate nature of service sto be provided, number of guards to be provided, shift change procedures, key daily activities and security vetting of guards
REVIEWERRequest to see a copy of the contract and/or service level agreement with the service provider.
There is no checklist for this element
NB Element 180: Perimeter fencing is intact
RESP
ONS
IBLE PERSON
Ensure that the perimeter fence is intact and the gates are functioning. Conduct a monthly walk about to ensure that perimeter fencing is intact, and gates are functioning
REVIEWERConduct a walk about to assess whether the perimeter fencing is intact and ask the systems manager of the nature of any breaches in the fence and if they were repaired.
There is no checklist for this element
NB Element 181: Secure Parking for staff is provided
RESP
ONS
IBLE PERSON Ensure that the facility has onsite secured parking for the staff. If the capacity of the hospital grounds is inadequate to provide secured parking then additional space nearby the hospital must be leased via procurement practices.
REVIEWER Observe whether there is onsite/off site secured staff parking.
There is no checklist for this element
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NB Element 182: There is a standard security guard room at the
entrances of the hospital
RESP
ONS
IBLE PERSON Ensure that the facility has a standard security guard room at the entrances of the hospital. The security guard room should have an alarm system linked to armed response; or safety officers should have a baton, handcuffs, cable ties, metal detectors; incident register; vehicle entrance registers.
REVIEWER Assess the security guard room whether the guard room has an alarm system linked to armed response; or safety officers have a baton, handcuffs, cable ties, metal detectors; incident register; vehicle entrance registers (Checklist 182).
CHECKLIST FOR ELEMENT 182
THERE IS A STANDARD SECURITY GUARD ROOM AT THE ENTRANCES OF THE HOSPITAL
Description Entrance 1 Entrance 2 Entrance 3 Entrance 4 Entrance 5
Does the facility have an alarm system linked to armed response (if Yes, checklist for security guardroom and security equipment must not be assessed. If No, assess checklist for security guardroom and security equipment)
Security guard room Entrance 1 Entrance 2 Entrance 3 Entrance 4 Entrance 5
Kitchenette – sink with cupboard underneath
Table
Chair
Functioning lights
Access to toilet
Security equipment for security officer(s)and accompanying stationery Entrance 1 Entrance 2 Entrance 3 Entrance 4 Entrance 5
Baton
Handcuffs OR Cable ties
Incident book
Metal detector
Telephone OR two-way radio OR dedicated cell phone
Vehicle entrance register
Total score
Total maximum possible score
Percentage score % % % % %
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NB Element 183: There are security guards on duty at all times
RESP
ONS
IBLE PERSON
A duty roster of security guards that monitor the facility for 24 hours is available at the facility.
REVIEWERReview the duty roster for security guards and assess whether they are present on duty.
There is no checklist for this element
NB Element 184: Security breaches are managed and recorded in a
register
RESP
ONS
IBLE PERSON Record all security breaches in a Register/Incident book. All incidents must be investigated and measures taken to rectify the security breaches should be recorded in the incident book. Sign off the incident after all necessary investigations and remedial actions are implemented.
REVIEWERReview the security breaches incident book. Assess whether security breaches are investigated and remedial action implemented.
There is no checklist for this element
Element 185: There is access control to specified areas
RESP
ONS
IBLE PERSON Control access to high-risk areas such as Maternity wards, Nursery, Pharmacy, Food storage areas via a digital or biometric system. Place Cameras strategically to record entry and exit.
REVIEWERObserve whether there is access control, to Maternity wards, Nursery, Pharmacy, Food storage areas via a digital or biometric system.
CHECKLIST FOR ELEMENT 185
THERE IS ACCESS CONTROL TO SPECIFIED AREAS
Description Score
Maternity ward
Nursery
Pharmacy
Accident and Emergency
Food storage areas
Total score
Total maximum possible score
Percentage score %
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Component 6: Support services
Sub-component 22: Food Services
COMMITMENT FOR SUB-COMPONENT 22: Monitor whether systems, processes and procedures are in place to provide adequate food services for patients
Patient Support Services – Food Services
ELE
ME
NTS
NB 186 A valid contract and Service Level Agreement for out sourced food services is available
NB 187 SOP for food services management is adhered to
NB 188 All equipment in the kitchen is functional
NB 189 Guidelines for storage, preparing and serving of food are adhered to
NB 190 A menu cycle of 8-12 days is available for all normal and therapeutic diets
NB 191 Schedule for meal times is adhered to
NB 192 Food parcels are provided to patients referred to other hospitals
Vital Essential NB Important
NB Element 186: A valid contract and Service Level Agreement for out sourced food services is available
RESP
ONS
IBLE PERSON If the food services are outsourced- Establish a service agreement with a reliable food service provider in accordance with procurement guidelines. The service level agreement must stipulate daily meal schedules, daily rations, and menu and hygiene practices.
REVIEWERRequest to see a copy of the contract and/or service level agreement with the service provider.
There is no checklist for this element
Who is responsible for this sub-component?
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NB Element 187: SOP for food services management is adhered toRE
SPO
NSIBLE PERSON
Ensure that the facility has hot water for washing dishes, clean and appropriate trolleys for transporting of meals and hand washing facilities for staff preparing food.
REVIEWER Verify whether the SOP for food management is adhered to by assessing whether there is hot water for dishwashing; dedicated trolleys for food deliveries; clean food trolleys and appropriate handwashing facilities are available (Checklist 187)
CHECKLIST FOR ELEMENT 187
SOP FOR FOOD SERVICES MANAGEMENT IS ADHERED TO
Desciption Score
Hot water is available for dishwashing
There are dedicated trolleys for delivery of food
Food trolleys are clean
Appropriate handwashing facilities are available
Total score
Total maximum possible score
Percentage score %
NB Element 188: All equipment in the kitchen is functional
RESP
ONS
IBLE PERSON
All the equipment in the kitchen must be functional. The food services manager must conduct fortnightly checks and any non-functional equipment must be repaired.
REVIEWERRequest the food services for information about the functionality of equipment within the kitchen and documentary proof of checks and request for repairs.
There is no checklist for this element
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NB Element 189: Guidelines for storage, preparing and serving of food are adhered to
RESP
ONS
IBLE PERSON Download the Guidelines for the storage, preparation and serving of food from the Department of Health website. Ensure that copy of these guidelines are available in the kitchen and conduct training of staff on the guideline.
REVIEWERevaluate whether the guidelines for storage, preparation and serving of food is adhered to.
CHECKLIST FOR ELEMENT 189
GUIDELINES FOR STORAGE, PREPARING AND SERVING OF FOOD ARE ADHERED TO
Desciption Score
Food services staff have received training on storage, preparing and food safety
Standardised therapeutic recipes posted in the food preparation and tray line areas to ensure correct, consistent meal preparation and portion size
Menus options to cater for patients’ religious and cultural needs
Storage
The temperatures on the fridges and freezers are monitored and recorded twice a day
Milk and meat stored at 4 degrees and frozen vegetables at – 18 degrees)
Dry goods must be stored off the floor
Dry goods must be protected from moisture
Raw and ready to eat food should be stored in separate cold stores
If no separate freezes or fridges then raw meat should be stred at the bottom of refrigerator
Food preparation areas are divided and separated according to the following food:
Raw meat
Fish
Vegetables
Infant’s feeds (if the hospital admits infants)
There is designated preparation equipment for raw meat ,fish and vegetables. OBS
(Guidance: These should be coloured coded, e.g. red for raw, brown for cooked meat, green for vegetables, etc.)
Serving of food
Food is kept covered when leaving the kitchen until served; either wrapped or in containers with fitted lids.
Heated trolleys must maintain a temperature of at least 63C
Total score
Total maximum possible score
Percentage score %
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NB Element 190: A menu cycle of 8-12 days is available for all normal and therapeutic diets
RESP
ONS
IBLE PERSON
Develop a menu for breakfast, lunch and supper for normal as well as therapeutic diets. This menu must be developed for a 8-12 day cycle.
REVIEWERRequest a copy of the menu for 8-12 days for both normal and therapeutic diets. Ask the food services manager if the above is adhered to or there are any deviations.
CHECKLIST FOR ELEMENT 190
A MENU CYCLE OF 8-12 DAYS IS AVAILABLE
Description Score
Normal diet
Therapeutic diet
Total score
Total maximum possible score
Percentage score %
NB Element 191: Schedule for meal times is adhered to
RESP
ONS
IBLE PERSON Develop a daily mealtime schedule for breakfast, lunch and supper for patients. Serve meals on schedule.
REVIEWERRequest a copy of the daily schedule for meal times. Ask patients if they receive their meals as per schedules and if there are any delays.
There is no checklist for this element
NB Element 192: Food parcels are provided to patients referred to other hospitals
RESP
ONS
IBLE PERSON Ensure that the hospital has a process for supplying meals for patients referred to other hospitals to cater for the duration of transport. Record this in the daily register where number of meals served is recorded.
REVIEWERRequest to see records of register where number of meals served daily is recorded. Assess whether any patients referred are recorded in the register.
There is no checklist for this element
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Component 6: Support services
Sub-component 23: Laundry
COMMITMENT FOR SUB-COMPONENT 23: Monitor whether systems, processes and procedures are in place to ensure clean linen for patients
Patient support services – Laundry
ELE
ME
NTS
NB 193 A valid contract and Service Level Agreement for out sourced laundry services is available
NB 194 SOP for the management of laundry is adhered to
NB 195 Guidelines for management linen is adhered to
NB 196 Planned maintenance of laundry equipment is according to the schedule
Vital Essential NB Important
NB Element 193: A valid contract and Service Level Agreement for out
sourced laundry services is available.
RESP
ONS
IBLE PERSON If the laundry services is not insourced than establish a service agreement with a reliable laundry service in accordance with procurement guidelines. A schedule for laundry collection and return must be part of the Service level agreement and this must be adhered to.
REVIEWERRequest to see a copy of the contract and/or service level agreement with the service provider.
There is no checklist for this element
Who is responsible for this sub-component?
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NB Element 194: SOP for the management of laundry is adhered to
RESP
ONS
IBLE PERSON Ensure that the facility has the correct SOP for the design, layout of the laundry. Demarcate the various areas with the laundry. Compile and inventory of all usable stock.
REVIEWER
Conduct a walk through and assess the design and layout of the laundry.
CHECKLIST FOR ELEMENT 194
SOP FOR THE MANAGEMENT OF LAUNDRY IS ADHERED TO
Description Score
The layout of the Laundry must be unidirectional (avoid mixing up of dirty linen and clean linen)
The following areas should be demarcated:
reception
sorting
scrub area
machine area
storage
There is an inventory list showing stock purchased, available, usable and due for disposal
Where an outsourced service provider is contracted, there is proper reconciliation of laundry stock by the contractor.
Total score
Total maximum possible score
Percentage score %
NB Element 195: Guidelines for management linen is adhered to
RESP
ONS
IBLE PERSON Sort the linen at the source into clean, soiled or infectious waste. The laundry must be sealed and transported on a wheeled trolley. Label the Clean laundry and transport to the relevant wards. The storage cupboard must be appropriately labelled.
REVIEWERObserve whether the laundry in the relevant wards are managed in accordance to the guidelines.
CHECKLIST FOR ELEMENT 195
GUIDELINES FOR MANAGEMENT LINEN IS ADHERED TO
Description Score
Clean, dirty, soiled and infectious linen is separated
Dirty, soiled and infectious linen are collected on a wheeled cart or trolley which is labelled, clean and covered
Clean linen are issued wheeled cart or trolley which is labelled, clean and covered
Storage cupboards are locked, well-organised and labelled
Total score
Total maximum possible score
Percentage score %
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NB Element 196: Planned maintenance of laundry equipment is according
to the schedule
RESP
ONS
IBLE PERSON Sign a service level agreement with an appropariate company for the maintenance of laundry equipment. Ensure that the schedule of planned maintenance s adhered to.
REVIEWER
Request the schedule for planned maintenance of laundry equipment enquire whether this has been adhered to.
There is no checklist for this element
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Component 6: Support services
Sub-component 24: Environmental health
COMMITMENT FOR SUB-COMPONENT 24: Monitor whether there are systems, processes and procedures in place to identify, mitigate and manage environmental health risks
System Manager
ELE
ME
NT
NB 197 Rodent and pest control is done according to schedule
NB 198 Portable water supply is sampled and tested according to schedule
NB 199 Stored water supply is sampled and tested according to schedule
NB 200 Air quality is tested according to schedule
NB 201 Environmental Health inspections conducted six monthly
NB 202 Quality Improvement plans for identified environmental health risks are implemented
Vital Essential NB Important
NB Element 197: Rodent and pest control is done according to schedule.
RESP
ONS
IBLE PERSON Establish a service agreement with a reliable rodent and pest control company in accordance with procurement guidelines. A schedule for rodent and pest control must be part of the Service level agreement and this must be adhered to.
REVIEWER Request the schedule for rodent and pest control and enquire whether this has been complied with.
There is no checklist for this element
Who is responsible for this sub-component?
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NB Element 198: Portable water supply is sampled and tested according
to schedule
RESP
ONS
IBLE PERSON Establish contact with the Water Department at the local municipality. Develop a schedule together with the Water Department for testing of portable water at the facility. Ensure that this schedule is adhered to.
REVIEWER Request the schedule for testing of portable water at the facility and enquire whether this has been complied with.
There is no checklist for this element
NB Element 199: Stored water supply is sampled and tested according to
schedule
RESP
ONS
IBLE PERSON Establish contact with the Water Department at the local municipality. Develop a schedule together with the Water Department for testing of stored water at the facility. Ensure that this schedule is adhered to.
REVIEWERRequest the schedule for testing of stored water at the facility and enquire whether this has been complied with.
There is no checklist for this element
NB Element 200: Air quality is tested according to schedule
RESP
ONS
IBLE PERSON Establish contact with the Air Quality Management Department at the local municipality. Develop a schedule together with the Air Quality Management Department for testing of air quality at the facility. Ensure that this schedule is adhered to.
REVIEWER Request the schedule for testing of air quality at the facility and enquire whether this has been complied with.
There is no checklist for this element
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NB Element 201: Environmental Health inspections conducted six
monthlyRE
SPO
NSIBLE PERSON Establish contact with the Environmental Health Department at the local municipality.
Ensure that the Environmental Health Practitioners conduct six monthly inspects for Rodents, Pest, Air quality, waste and healthcare waste.
REVIEWERRequest the certificate or report on environmental inspections for Rodents, Pest, Air quality, waste and healthcare waste.
CHECKLIST FOR ELEMENT 201
ENVIRONMENTAL HEALTH INSPECTIONS ARE CONDUCTED SIX MONTHLY
Description Score
Rodents
Water
Air quality
Pest control
Health waste
Total score
Total maximum possible score
Percentage score %
Element 202: Quality Improvement plans for identified environmental health risks are implemented
RESP
ONS
IBLE PERSON
Conduct an analysis of the environmental health risks based on inspection and other related reports. Prioritise the risk and develop risk mitigation strategies.
REVIEWERRequest the environmental health risks reports and inspect whether the action plans have been implemented
CHECKLIST FOR ELEMENT 202
QUALITY IMPROVEMENT PLANS FOR IDENTIFIED ENVIRONMENTAL HEALTH RISKS ARE IMPLEMENTED
Description Score
Rodents
Water
Air quality
Pest Control
Health waste
Total score
Total maximum possible score
Percentage score %
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Component 6: Support services
Sub-component 25: Mortuary
COMMITMENT FOR SUB-COMPONENT 25: Monitor whether there are systems, process and procedures in place to manage mortal remains
Mortuary Services
ELE
ME
NTS
NB 203 A functional mortuary is onsite
NB 204 The temperature of the refrigerators is recorded twice daily
NB 205 Cleaning materials used in the mortuary have been approved by the relevant authority.
NB 206 SOP for management of mortal remains are adhered to
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 203: A functional mortuary is onsite
RESP
ONS
IBLE PERSON
A functional mortuary must be available onsite at all hospitals in order to manage the mortal remains of patients.
REVIEWER
Assess whether onsite mortuary is functional.
CHECKLIST FOR ELEMENT 203
A FUNCTIONAL MORTUARY IS ONSITE
Description Score
The mortuary is easily accessible to mortuary staff and related service providers
Rerigerated rooms for Body-storage systems are available
Body cabinets for Body-storage systems are available
Single shelves available for storage of bodies
Shelves are made of stainless steel
Shelves are free from rust
The long-term storage of bodies are to be kept at a lower temperature
The following clearly marked areas are available within the mortuary:
Reception area for members of the public
Ablution areas for staff
Visitors’ admin space close to the reception area
Staff admin space close to the point where a body is delivered to the mortuary
Office space for pathologists to write up reports
Waiting and circulation areas for visitors to the mortuary.
Viewing room, from where a body can be viewed through a curtained glass window
Body-display room, where a body is placed for identification purposes
Body preparation area
Shower facilities (staff) .
Changing room (staff)
Storage space for equipment and clothing that is worn in the body-preparation and autopsy spaces
Body-storage facility (cold room or refrigerated cabinets),
Total score
Total maximum possible score
Percentage score %
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NB Element 204: The temperature of the refrigerators is recorded twice
daily
RESP
ONS
IBLE PERSON
Temperature control is vital for the storage of mortal remains of patients. Record the temperature twice daily and address any potential deviations.
REVIEWERMeasure the temperature of the refrigerators in the mortuary and check whether the temperature is recorded twice daily.
There is no checklist for this element
NB Element 205: The relevant authority has approved cleaning materials
used in the mortuary.
RESP
ONS
IBLE PERSON Cleaning material that is approved by the relevant authority is required for the mortuary. Obtain A list of approved cleaning material from Emergency Medical Services or Forensic Services and ensure that supply chain procures the specific cleaning material.
REVIEWERObtain a list of the approved cleaning material for mortuary. Request the items used for cleaning the mortuary and assess them against the approved list.
There is no checklist for this element
NB Element 206: SOP for management of mortal remains are adhered to.
RESP
ONS
IBLE PERSONMortal remains should be placed in a polythene bag, sealed in an air tight container, embalmed and placed in a non-transparent coffin. Maintain a register for mortal
REVIEWERUse checklist 206 to assess whether the SOP for management of mortal remains is adhered to.
CHECKLIST FOR ELEMENT 206
SOP FOR MANAGEMENT OF MORTAL REMAINS ARE ADHERED TO
SOP for management of mortal remains are adhered to Score
Human remains are placed in a polythene bag, sealed in an airtight container, placed in a sturdy non-transparent sealed coffin, embalmed
An updated register of mortal remains is available
Total score
Total maximum possible score
Percentage score
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Component 7: Infrastructure
Sub-component 26: Physical space and non-medical equipment
COMMITMENT FOR SUB-COMPONENT 26: Monitor whether the physical space is adequate and functional for the hospital workload, and whether timely maintenance is undertaken
Infrastructure, but each service and operational area is required to be compliant
ELE
ME
NT
207 Hospital space accommodates all service and support areas
208 There are approved plans for all buildings in the hospital
209 All building(s)are compliant with safety regulations
210 All building (s) are maintained according to a schedule
211 Piped medical gas supply is available
212 Piped and portable suction is available
213 There is a process for emergency and adhoc repairs to non-medical equipment and infrastructure
Vital Essential NB Important
Who is responsible for this sub-component?
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Element 207: Hospital space accommodates all service and support areas
RESP
ONS
IBLE PERSON Establish whether the facility has sufficient space to accommodate all service and support areas based on the category of hospital and package of services provided. If the space is insufficient then write a motivation to the relevant authority (District/Province)
REVIEWERUse checklist 207 to assess if the hospital space accommodates all service and support areas.
CHECKLIST FOR ELEMENT 207
HOSPITAL SPACE ACCOMMODATES ALL SERVICE AND SUPPORT AREAS
General Score
Main waiting area
Help desk/Reception/patient registration
Toilets
Clinical Service Areas Accident & Emergency
Triage
Consulting room
Counselling room
Observation area
Emergency/resuscitation room
Support /administration areas Accident & Emergency
Unit manager office
Staff tea room with kitchenette
Medicine store room/cupboard/trolley
Surgical stores store-room
Lockable cleaning material store room OR cupboard
Dirty utility room
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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CHECKLIST FOR ELEMENT 207
HOSPITAL SPACE ACCOMMODATES ALL SERVICE AND SUPPORT AREAS
General Score
Linen room OR cupboard
Disaster stores room
Dr’s rest room
Exterior space
Parking spaces
Staff parking space
Disabled parking space
Ambulance parking space
Total score
Percentage score %
Element 208: There are approved plans for all buildings in the hospital
RESP
ONS
IBLE PERSON Establish whether the facility has approved building plans. If the facility is unaware or do not have them a request should be made to the municipality for a copy of the building plans.
REVIEWERRequest to see a copy of the hospital building plans. Establish whether all buildings in the current structure are included in the plans.
There is no checklist for this element
Element 209: All building(s)are compliant with safety regulations
RESP
ONS
IBLE PERSON
To be compliant with safety regulations, the facility requies an updated fire certificate, electrical compliance certificate, engineers certificate and plumbing certificate.
REVIEWERRequest to see a copy of the certificates listed in Checklist 209. Ensure that these certificates are current and not expired.
CHECKLIST FOR ELEMENT 209
ALL BUILDING(S)ARE COMPLIANT WITH SAFETY REGULATIONS
Description Score
Fire compliance certificates
Engineers certificate
Plumbing compliance certificate
Electrical compliance certificates
Total score
Percentage score %
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Element 210: All building (s) are maintained according to a schedule
RESP
ONS
IBLE PERSON Main the hospitals buildings according a schedule. The infrastructure department must develop a schedule for building maintenance and this should be available for all service and support areas.
REVIEWERRequest to see a copy of the maintenance schedule for the buildings. During the facility walk about enquire form staff if maintenance has been conducted in accordance with the schedule. Use checklist 210 to assess compliance
CHECKLIST FOR ELEMENT 210 A (APPLICABLE TO ALL BUILDINGS)
ALL BUILDING (S) ARE MAINTAINED ACCORDING TO A SCHEDULE
Area and measures Scores
EXTERIOR OF BUILDING(S)
Walls - paint in good condition Roof intact
GUTTERS
a. Intact
b. Paint in good condition
DOORS AND GATES
a. Working condition
b. Handles working
c. Open and close
LIGHTS
a. Present
b. Functional
C. Paving is intact
Total score
Total maximum possible scor
Percentage score
CHECKLIST FOR ELEMENT 210B (INTERIOR OF BUILDINGS)
Area and measures Scores
INTERIOR OF BUILDING(S)
Toilets present
Wall mounted paper towel dispenser(s)
Wall mounted hand soap dispenser(s)
Wall tiles in good condition
Walls - paint in good condition
CEILING
a. Presentb. Paint in good condition
c. Intact
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CHECKLIST FOR ELEMENT 210B (INTERIOR OF BUILDINGS)
LIGHTS
a. Present
b. Functional
WINDOWS
a. Window panes intact (glass not broken)
b. Handles working
c. Windows can open and close
DOORS
a. Present
a. Intact
b. Handles working
c. Open and close
HAND WASH BASINS
a. Present
b. Intact
c Taps functional (with running water)
VENTILATION
Adequate natural (windows) OR mechanical ventilation (ceiling fans/air conditioner)
Total score
Total maximum possible scor
Percentage score
CHECKLIST FOR ELEMENT 210 C (APPLICABLE TO THEATRE, PHARMACY & ISOLATION WARD)
Mechanical ventilation (must be present)
Present
Intact
Functional
Total score
Total maximum possible scor
Percentage score
Total score for checklist 210 a + 210b + 210c
Total maximum possible score (sum of all samples scores minus those marked NA) for checklist 210a +210b+210c
Percentage score
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Element 211: Piped medical gas supply is available
RESP
ONS
IBLE PERSON Enter into a service level agreement with a reliable supplier for the provision of piped medical gas. This should be available in emergency department, theatre, high care/ICU, nursery and maternity/labour wards. Check The supply of piped medical gas daily. Main the hospitals buildings according a schedule.
REVIEWER
Assess whether piped medical gas is available by turning on the valves. Request a copy of the daily checklist and signature to see if has been checked daily.
There is no checklist for this element
Element 212: Piped and portable suction is available
RESP
ONS
IBLE PERSON Piped and portable suction should be available in emergency department, theatre, high care/ICU, and nursery and maternity/labour wards.
REVIEWER
Assess whether piped and portable suction. Test the suction units to assess whether the units are functional.
There is no checklist for this element
Element 213: There is a process for emergency and adhoc repairs to non-medical equipment and infrastructure
RESP
ONS
IBLE PERSON Adhoc repairs and maintenance may be required at the facility. Establish a process for the emergency and adhoc repairs of non-medical equipment and infrastructure..
REVIEWER
Request a copy of the standard operating procedure if available. Interview staff and assess whether they are aware of the process for emergency and adhoc repairs of non-medical equipment and infrastructure.
There is no checklist for this element
Accident & Emergency unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
CHECK IN THESE
FUNCTIONAL AREAS
Accident & Emergency unit Maternity unit Intensive Care/
High Care Theatre
CHECK IN THESE
FUNCTIONAL AREAS
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Component 7: Infrastructure
Sub-component 27 : Bulk supplies
COMMITMENT FOR SUB-COMPONENT 27: Monitor whether the required electricity supply, water supply and sewerage services are constantly available
Systems Management but each service and operational area is required to be compliant
ELE
ME
NTS
214 Hospital has functional un-interrupted potable water supply
215 Hospital has emergency water supply
216 Hospital has a functional back-up electrical supply available in designated areas
217 The sewerage system is functional
Vital Essential NB Important
Element 214: Hospital has functional un-interrupted potable water supply
RESP
ONS
IBLE PERSON The facility in cooperation with the municipality ensure that there is piped water supply available at all times to the facility. The 24-hour contact number of the local municipality’s water supply department must be prominently displayed on the facility’s notice board together with other emergency numbers of essential services.
REVIEWEROpen the water taps in all service and operational areas to determine whether there is water supply. Ask the relevant manager about water supply interruptions.
There is no checklist for this element
Who is responsible for this sub-component?
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Element 215: Hospital has emergency water supply
RESP
ONS
IBLE PERSON The facility manager must ensure that there is a backup supply of water in the event of interruptions to supply. Ensure that the municipality fills water tanks and these are checked on a fortnightly basis. Arrange water tankers when there is an interruption of water supply.
REVIEWERAssess whether water tanks are available. Ask the relevant manager as to when these tankers are checked, process for re-filling and availability of water tankers.
There is no checklist for this element
Element 216: Hospital has a functional back-up electrical supply available in designated areas
RESP
ONS
IBLE PERSON
Ensure that a generator is permanently stationed at the facility, or an Uninterrupted Power Supply (UPS) or Solar power is available for back-up in the event of an electrical failure. If a generator is present, assign a staff member to check the fuel levels on a monthly basis and after every use. Prominently display thee emergency contact number for the generator maintenance on the facility notice board.
REVIEWERAssess whether back-up electricity supply is available in designated service areas. Ask the relevant manager as to the process for re-fuelling the generator.
There is no checklist for this element
Element 217: The sewerage system is functional
RESP
ONS
IBLE PERSON Ensure that the facility has a piped sewerage removal system or a septic tank system. Prominently display the emergency contact number for the district maintenance services and the local municipality on the facility notice board.
REVIEWERAssess whether the piped sewage system is functional. There must also be no leaking drainpipes outside the building.
There is no checklist for this element
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Component 7: Infrastructure
Sub-component 28: Health technology
COMMITMENT FOR SUB-COMPONENT 28: Monitor whether essential equipment, instruments and required furniture are available
Systems Management, Supply chain management and Financial Management but each service and operational area is required to be compliant
ELE
ME
NTS
NB 218 Furniture is available and intact in all service and support areas
219 Essential medical equipment is available and functional
220 All health technology is certified/licensed
221 Resuscitation room is equipped with functional basic equipment
222 Essential equipment and instruments for surgery are available
223 Intensive care units/High care unit is equipped with functional basic equipment
224 Essential instruments for obstetric are available
225 Schedule for Planned maintenance of medical equipment is adhered to
NB 226 SOP for reactive maintenance of medical equipment is available
227 Piped medical gas supply is maintained
228 Oxygen cylinders with oxygen gauge are available
NB 229 Redundant and non-functional equipment are removed from the hospital according to guidelines
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 218: Furniture is available and intact in all service and
support areas
RESP
ONS
IBLE PERSON Obtain a list of essential furniture required for each consulting room and operational area. Using the list conduct a quarterly audit to assess whether the furniture is available, intact and functional.
REVIEWER
Request a copy of quarterly audit of furniture for each service and operational area.
CHECKLIST FOR ELEMENT 218
FURNITURE IS AVAILABLE AND INTACT IN ALL SERVICE AND SUPPORT AREAS
Description Score
WAITING AREAS
Seating
a. Adequate seating for all patients
b. Chairs / benches intact
Notice boards available
Notice boards available
CONSULTING ROOMS/INPATIENT WARDS
Desk
a. Available
b. Intact (including the drawers)
Chair (clinician)
a. Available
b. Intact
At least 1x chair (patient)
a. Available
b. Intact
Tilting examination couch
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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CHECKLIST FOR ELEMENT 218
FURNITURE IS AVAILABLE AND INTACT IN ALL SERVICE AND SUPPORT AREAS
Description Score
a. Available
b. Intact
Bedside footstool
a. Available
b. Intact
Lockable medicine cupboards
a. Available
b. Intact
Dressing trolley (at bedside for examination equipment)
a. Available
b. Intact (including the drawers)
Lockable medicine trolley
a. Available
b. Intact
Hospital Bed with side restraints
a. Available
b. Intact
Drip stand
a. Available
Instrument trolley
a. Available
b. Intact
Bar fridge
a. Available
b. Intact
Total score
Total maximum possible score
Percentage score %
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Element 219: Essential medical equipment is available and functional
RESP
ONS
IBLE PERSON Obtain a list of essential equipment required for services. Using the list conduct a monthly audit to assess whether the essential equipment is available, intact and functional in all consultation rooms.
REVIEWER
Request a copy of monthly audit of essential equipment for each service area.
CHECKLIST FOR ELEMENT 219
ESSENTIAL MEDICAL EQUIPMENT IS AVAILABLE AND FUNCTIONAL
Item Score
Stethoscope
Non-invasive Baumanometer (wall mounted/ portable)
Adult, paediatric and large cuffs (3) for Baumanometer
Diagnostic sets -including ophthalmic pieces(wall mounted or portable)
Patella hammer
Tuning fork (only required in one consultation room)
Tape measure
Clinical thermometers
Wall mounted or portable angle poise style examination lamp
Blood glucometer
Peak flow meter
Adult clinical scale up to 150 kg
HB meter
Height measure
Urine specimen jars
Baby scale
Bassinet
Score for all rooms
Maximum possible score
Percentage score %
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
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Element 220: All health technology is certified/licensedRE
SPO
NSIBLE PERSON All health technology purchased must meet approved regulatory standards such as
South African Bureau of Standards. If regulations require that the health technology be licenced the Licence should be available.
REVIEWER
Assess a sample of five major equipment and inspect whether the equipment has standards specification/licence and approval.
There is no checklist for this element
Element 221: Resuscitation room is equipped with functional basic equipment
RESP
ONS
IBLE PERSON Equip the resuscitation rooms in emergency areas, obstetrics, inpatient wards and consultations areas with the necessary equipment to attend to emergencies. Restock the resuscitation room, trolley, and audit daily.
REVIEWER
Request a daily record of the audit and restock of the resuscitation room.
CHECKLIST FOR ELEMENT 221
RESUSCITATION ROOM IS EQUIPPED WITH FUNCTIONAL BASIC EQUIPMENT
Item ScoreEmergency trolley with lockable medicine drawer and accessories
Examination couch
Wall or ceiling mounted angle poise style examination lamp
Nebuliser OR face mask with nebuliser chamber for adult and paediatric
Functional electric powered OR manual suction devices and suction catheters
Kick about with bucket
Anaesthetist stool (round stool on wheels)
Drip stand
Dressing trolley
Cardiac arrest board
Thermal (space) blanket
Suture material
Gloves exam n/sterile gloves: small, medium and large at least one pair of each size
Gloves surgical sterile latex: 6 OR 6.5, 7 OR 7.5 and 8 at least one pair of each size
Protective face shields OR goggles with face mask
Disposable plastic aprons
Disposable non-sterile face masks
Resuscitation algorithms
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
CHECK IN THESE
FUNCTIONAL AREAS
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CHECKLIST FOR ELEMENT 221
RESUSCITATION ROOM IS EQUIPPED WITH FUNCTIONAL BASIC EQUIPMENT
Item ScoreResuscitation documentation register
Wall mounted liquid hand soap dispenser
Wall mounted hand paper dispenser
Equipment for neonatal resuscitation ScoreMucus catheter (sterile), rubber, open-ended, 15 French gauge
Nasal catheter (sterile), rubber, open-ended, 8 French gauge
Endotracheal tubes, sterile, 12 French gauge
Curved stylet, sterile (for stiffening endotracheal tube when intubation is difficult)
Suction catheters, sterile, 6 French gauge
Infant laryngoscope (Magill), with spare bulb and batteries
Ventilator bagOxygen cylinder, either with 40-cm water manometer and flowmeter or with safety valve and rubber bag (simple resuscitator)Infant face masks
Airways
Umbilical vein catheters, sterile
Heat source
Thermometer, low-reading
Mouth suction device (Delee)
Total score
Percentage score %
Element 222: Essential equipment and instruments for surgery are available
RESP
ONS
IBLE PERSON Equip the theatres with the required essential equipment to perform procedures. Determine the minimum quantity by the theatre utilisation rate. Using the list conduct a quarterly audit to assess whether the essential equipment and instruments for surgery is available, intact and functional.
REVIEWER
Request a copy of quarterly audit of essential equipment and instruments for surgery.
CHECKLIST FOR ELEMENT 222
ESSENTIAL EQUIPMENT AND INSTRUMENTS FOR SURGERY ARE AVAILABLE
Item Quantity Size Score
GENERAL INSTRUMENTS
Sponge forceps (Rampley)
Instrument pins (Mayo) 4 25 cm
Towel clips (Backhaus) 4
Artery forceps (Crile):
straight 6 11 cm
curved 6 16 cm
Artery forceps (mosquito):
straight 6 16 cm
curved 6 13 cm
Curved artery forceps (Mayo or Kelly) 6 13 cm
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CHECKLIST FOR ELEMENT 222
ESSENTIAL EQUIPMENT AND INSTRUMENTS FOR SURGERY ARE AVAILABLE
Item Quantity Size Score
Straight artery forceps (Spencer Wells) 6 20 cm
Tissue forceps (Allis) 6 20 cm
Standard dissecting forceps:
toothed 4 15 cm
non-toothed 2 14.5 cm
Long dissecting forceps, toothed 2 14.5 cm
Long dissecting forceps, non-toothed 1 25 cm
Straight dissecting scissors (Mayo) 1 25 cm
Curved dissecting scissors (Mayo) 2 17 cm
Dissecting scissors (Metzenbaum) 1 23 cm
Stitch scissors, with blunt ends 1 18 cm
Rake retractors (Volkmann), 4-toothed 2 15 cm
Rake self-retaining retractors 2 22 cm
Retractors (Langenbeck):
narrow 2 21 cm
medium 2 6.0 mm wide
Retractors (Deaver): 2 9.5 mm wide
medium
large 1 25 mm blade
Hook retractors 1 75 mm blade
Needle holders (Mayo):
medium 2 15 cm
large 9 15 cm
Scalpel handles No. 3 (Bard-Parker) 2 17.5 cm
Scalpel handles No. 4 (Bard-Parker) 12
Scalpel handles No. 5 (Bard-Parker) 12
Suction nozzle (Yankauer) 4
Nozzle (Poole-Wheeler) 1 28.5 cm
Diathermy electrodes, coagulating and fulgurating 1
Flexible probe, with round point 2
Grooved director (Kocher) 1 20 cm
Stainless-steel sponge bowls:
small 6
medium 6
large 6
Stainless-steel kidney dishes:
small 4
medium 4
large 4
Stainless-steel gallipots
Sinus forceps 2
Abdominal instruments
Self-retaining retractor with 3 blades (Balfour) 1
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CHECKLIST FOR ELEMENT 222
ESSENTIAL EQUIPMENT AND INSTRUMENTS FOR SURGERY ARE AVAILABLE
Item Quantity Size Score
Proctoscope (anal speculum, Goligher):
child-size 1 6 cm
adult-size 1 7.5 cm
Sigmoidoscope, complete with pump:
child-size 1
adult-size 1
Light source with cable, to fit sigmoidoscope 1
Biopsy forceps 2
Clamps (Moynihan), box-joint 6 23 cm
Gallbladder trocar and cannula (Ochsner) 1
Gallstone forceps (Desjardin) 1
Malleable probe and scoop (Moynihan) 1
Lacrimal probes, set of 3 1
Tissue forceps (Duval):
medium 2 15.5 cm
large 2 19 cm
Crushing clamps (Payr):
small 2 21 cm
large 2 36 cm
Crushing clamps (Schoemaker):
small 2 17 cm
large 2 20 cm
Malleable copper retractors (spatulae) 2
Occlusion clamps (Doyen):
straight 2 22.5 cm
curved 2 22.5 cm
Twin occlusion clamps (Lane) 1 31.8 cm
Intestinal tissue-holding forceps (Babcock) 4 24.0 cm
Glass rods 2
GYNAECOLOGY INSTRUMENTS
Vaginal specula (Sims):
small 1 1
large 1 3
Weighted vaginal speculum (Auvard) 1 38 × 75 mm
Vulsellum forceps (Teale or Duplay) 2 28 cm
Episiotomy scissors 2
Vacuum extraction apparatus 1
Amniohook 1
Uterine sound (Simpson) 1 30 cm
Double-ended uterine dilators, set of 6 1
26 × 7 mm to 26 ×14 mm (various sizes)
Uterine curettes (Sims) 1 24 cm
Ovum forceps (de Lee) 1
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CHECKLIST FOR ELEMENT 222
ESSENTIAL EQUIPMENT AND INSTRUMENTS FOR SURGERY ARE AVAILABLE
Item Quantity Size Score
Cranial perforator 6 22.5 cm
Straight hysterectomy forceps (Péan) 2
Craniotomy forceps 8 20 cm
Uterine haemostasis forceps (Green-Armyrage)
Conjunctival scissors 2
Conjunctival forceps 1
Extracapsular forceps 1
Chalazion clamp 1
Chalazion curettes, set of 3 sizes 1
Enucleation scissors 1
Straight ring scissors 1
Spring scissors (Westcott)
Corneal scissors (Castroviejo):
right 1
left 1
Iris scissors 2
Iris forceps 1
Needle holder, curved with lock (Castroviejo) 1
Operating loupe (or similar magnifying device) 1
Capsule forceps, non-toothed 1
Simple ball-type cautery 2
Muscle hooks 2
Strabismus hooks 1
Cystotome 1
Vectis 1
Periosteal elevator 1
Iris retractor 1
Iris spatula (repositor) 1
Irrigating cannula 1
Meibomian curette 1
Eyelid clamp (and/or Trabut plate) 1
Flat cataract curette 1
Knife needle 1
Spirit lamp with hot-point cautery 1
Tear-duct probes 1
Irrigating cannula 1
Air cannula 1
ORTHOPAEDIC INSTRUMENTS
Plaster instruments:
plaster saw (Tenon) 1
plaster saw (Engel) 1
shears (Stille) 1 46 cm
scissors (Böhler) 1 25 cm
opening shears (Daw) 1
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CHECKLIST FOR ELEMENT 222
ESSENTIAL EQUIPMENT AND INSTRUMENTS FOR SURGERY ARE AVAILABLE
Item Quantity Size Score
bandage scissors (Lister) 1
plaster spreader 1
Pneumatic tourniquet 1
Rubber bandages (Esmarch) 2
Pins (Steinmann), with covers for ends
Hand chuck for introducing pins (T-handle) 1
Stirrups (Böhler)
Wires (Kirschner)
Wire stirrups (Kirschner) 6
Hand drill and drill bits (Zimmer) 1 set
Mallet (Heath) 1 38 mm head
Small mallet 1
Straight osteotomes (Stille):
broad 2 18 × 160 mm
narrow 2 6 × 160 mm
Straight chisels (Stille) 2
Straight gouges 2
Orthopaedic self-retaining retractor 1
Tissue forceps (Lane) 2
Spoons (Volkmann):
small 1 17 cm
medium 1 21 cm
Amputation knife 1 20 cm
Amputation saw (Satterlee) 1
Finger saw 1
Bone-holding forceps (Fergusson or Lane) 2
Bone levers (Lane) 2
Rugine (Farabeuf) 1
Compound-action bone nibbler (rongeur) 1
Compound-action bone-cutting forceps 1 19 cm
Bone file 1
Skull callipers (Crutchfield) 1
Skull callipers (Cone), with spanner 1
Auriscope and aural specula 1 set
Otolaryngology instruments
Ear syringe 1
Head mirror 1
Nasal specula (Thudicum), set of 4 sizes 1
Angled dressing forceps (Tilley) 2
Self-retaining retractor (West) 1
Aural probe, hook, and curette 1 set
Myringotome 1
Mouth gag (Boyle - Davis):
Angled tongue depressors 2
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CHECKLIST FOR ELEMENT 222
ESSENTIAL EQUIPMENT AND INSTRUMENTS FOR SURGERY ARE AVAILABLE
Item Quantity Size Score
Small suction tubes 9
Small catspaw retractors (Kilner) 9
Tracheal dilator (Bowlby) 1
Assorted tracheostomy tubes or tracheostomy sets
Urogenital instruments
Curved urethral bougies (Clutton) 2 sets 10-24 Ch.
Straight bougies (Powell) 2 sets 10-24 Ch.
Filiform bougies2 sets
33 cm long
Bougies (Guyon), for use as filiform guide 2-6 Ch.
Bougies, 5/8 of a circle, olive-tipped (Hey Grove), set of 3 1
Soft penile clamps 9
Suprapubic trocars and cannulas 1 25 Ch.
Catheter introducer (Malecot) 1 30 Ch.
Catheter introducer (Foley) 1
Vascular instruments
Bulldog clamps 4 22 mm
Clamps (Satinsky), with 3 different blade shapes 1 set
Narrow-jaw needle holders (Hegar)
EQUIPMENT
Theatre equipment Quantity Size Score
FIXED EQUIPMENT
Fixed operating-room light
Ultraviolet light source
Scrub basins with hot and cold running water
Exhaust fans 1
Electric autoclave with horizontal drum 1
Electric or kerosene sterilizer for boiling instruments
OTHER EQUIPMENT
Operating table, universal frame-type with headpiece 1
Plaster, orthopaedic fracture table (modified Watson-Jones) 1
Utensil sterilizer for bowls, boiling-type 1
Electric or kerosene hot-air sterilizer 2
Forceps sterilizers (Cheatle), heavy-duty 2
Forceps sterilizers (Harrison) 4
Instrument trolleys 2
Anaesthetic trolleys 4
Instrument stands with trays (Mayo)
Instrument stands with bowls: 2
Stands for swabs 2
Portable aspirating surgical suckers, electric 2
Portable aspirating surgical suckers, foot-operated
Cylindrical sterilizing drums: 4
Stainless-steel buckets with covers 4
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CHECKLIST FOR ELEMENT 222
ESSENTIAL EQUIPMENT AND INSTRUMENTS FOR SURGERY ARE AVAILABLE
Item Quantity Size Score
“Kick-about” receptacles, on frames with roller casters 4
Revolving operating stools of adjustable height (enamel finish) 2
Footstools
Dressing trays: 4
Portable operating-room lights, with stands 1
Diathermy machine 2
Radiograph viewing boxes 2
Dispensers for hot and cold sterile distilled water (4 litres/hour) 4
Stretchers with combination wheel and adjustable sides 2
Labour and delivery beds, with two-piece mattresses 4
Folding stretchers 4
Orthopaedic equipment
Frames with pulleys (Böhler-Braun)
Pulley systems:
Wooden spreader bars, square:
Non-elastic traction cord
Blocks (for elevating bed), 22 cm and 30 cm high
Overhead traction suspension frames
Weights for traction
Anaesthetic equipment
Laryngoscopes 12
Spare bulbs for laryngoscopes
30 (or 8 rechargeable batteries + charger)
Batteries for laryngoscopes
Magill’s intubating forceps (in an emergency, ovum forceps can be used instead) 3 for each tube size
Endotracheal tube connectors, 15 mm plastic (can be connected directly to the breathing valve) 4
Catheter mounts (sometimes also called endotracheal tube connectors), antistatic rubber
Breathing hose and connectors: 2
Breathing valves (universal non-rebreathing type): 2
Breathing systems (for continuous-flow anaesthesia) (Boyle’s) 2
SELF-INFLATING BELLOWS OR BAGS
Anaesthetic vaporizers, for ether, halothane, and trichloroethylene (draw-over type)
Needles and cannulas for intravenous use, including paediatric sizes and an umbilical vein catheter
Operating gowns, face masks and caps 2
Plain gauze and cotton-wool swabs 1
Lithotomy set (for combined procedure) 3
Total score
Percentage score %
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Element 223: Intensive care units/High, care unit is equipped with functional basic equipment
RESP
ONS
IBLE PERSON
Equip the intensive care units/ high care units with the required functional basic equipment to perform procedures. Using the checklist conduct a quarterly audit to assess whether the functional basic equipment for intensive care units is available, intact and functional.
REVIEWERRequest a copy of quarterly audit of functional basic equipment for the intensive care units.
CHECKLIST FOR ELEMENT 223
INTENSIVE CARE UNITS/HIGH CARE UNIT IS EQUIPPED WITH FUNCTIONAL BASIC EQUIPMENT
ADULT ICU/HIGH CARE Quantity Size Score
Defibrillator
ECG Machine
Laryngoscope
Multiparameter monitor
Pulse Oximeter
Transport Ventilator(pneumatic)
Ventilator (Basic)
Advanced Ventilator
Infusion Pump
Syringe Pump
Ophthalmoscope
Stethoscope
Blood Pressure Apparatus
Reverse Osmosis plant (Portable)
Electronic Weighing Machine
Continuous renal replacement therapy
Colour Doppler for general purpose
Intra Aortic Balloon Pump
Non Invasive Cardiac Monitor
Portable X Ray Machine
DVT Pumps/leg compression device
Nebulizer
Patient warming System Air Warmer
Pacemaker
Feed Pump
Blood Warmer
Et Co2 Monitor
Transport Monitor
Dialysis Machine
Patient Controlled Anesthesia Pumps
Mini Doppler
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CHECKLIST FOR ELEMENT 223
INTENSIVE CARE UNITS/HIGH CARE UNIT IS EQUIPPED WITH FUNCTIONAL BASIC EQUIPMENT
ADULT ICU/HIGH CARE Quantity Size Score
Suction Machine
Central Monitor
Bipap/cpap
Air bed
Patient bed motorized
X ray viewer box
Cervical collar
Ambu bag mask set
Electronic needle destroyer
Flash autoclave
Oxygen flow meter
Suction unit
Bedpan washer
ICU pendants
Computer with flat-screen monitor
Multi-parameter patient monitor
NEONATAL ICU/HIGH CARE
ITEM Quantity Size Score
High care bed
ICU bed
Closed incubator
ICU crib
Cardiac table
Ambubag - infant
Double O2 flowmeter
O2 blender
Suction
Phototherapy lights
Neo-puff
Infusion pump
Syringe pump
Mulitparameter monitor (To , pulse, resp, SpO2, NIBP, iBP)
Mulitparameter monitor (To , pulse, resp, SpO2, NIBP, iBP, ETCO2)
CPAP with humidifier
Ventilator with humidifier
SiPAP with humidifier
Total score
Percentage score %
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Element 224: Essential instruments for obstetric are availableRE
SPO
NSIBLE PERSON
Ensure that Essential obstetric instruments for normal vaginal delivery, episiotomy, and insertion of contraceptive devices and evacuation of uterus are available in sufficient quantity at the hospital. The instruments must be sterilised after each use. Determine the minimum quantity based on utilisation rate. Using the list conduct a quarterly audit to assess whether the essential instruments for obstetrics is available, intact and functional.
REVIEWER
Request a copy of quarterly audit of essential instruments for obstetrics.
CHECKLIST FOR ELEMENT 224
ESSENTIAL INSTRUMENTS FOR OBSTETRIC ARE AVAILABLE
Item Quantity Size Score
Stainless steel instrument tray with cover, 31 × 20 × 6 cm 6
Towel clips (Backhaus box lock) 1
Sponge forceps, 22.5 cm 1
Straight artery forceps, 16 cm
Uterine haemostasis forceps (Green-Armytage), 20 cm 10 packets
Hysterectomy forceps, straight (Péan), 22.5 cm 2 packets
Mosquito forceps, 12.5 cm 2 packets
Tissue forceps (Allis), 19 cm 1
Uterine tenaculum forceps, 28 cm 2
Needle holder, straight (Mayo), 17.5 cm 1
Surgical knife handle 1
Surgical knife blades 1
Triangular point suture needles, 7.3 cm, size 6 1
Round-bodied needles No. 12, size 6 1
Abdominal retractor (Deaver), size 3, 2.5 × 22.5 cm 1
Abdominal retractors, double-ended (Richardson) 2
Curved operating scissors, blunt pointed (Mayo), 17 cm 2
Abdominal self-retaining retractor (Balfour) with 3 blades
Straight operating scissors, blunt pointed (Mayo), 17 cm
Scissors, straight, 23 cm
Suction nozzle
Suction tube, 22.5 cm, 23 French gauge
Intestinal clamps, curved (Dry), 22.5 cm 12 pairs of each
Intestinal clamps, straight, 22.5 cm 3
Dressing (non-toothed tissue) forceps 2
Instruments for evacuation of uterus Quantity Size Score
Sponge forceps 2
Vaginal speculum, large (Sims) 2
Self-retaining vaginal retractor (Auvard) 1
Vulsellum forceps (Teale) 1
Uterine sound (Simpson) 1
Uterine dilators, double-ended (Hegar), set of 6 1
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CHECKLIST FOR ELEMENT 224
ESSENTIAL INSTRUMENTS FOR OBSTETRIC ARE AVAILABLE
Item Quantity Size Score
Uterine curettes Quantity Size
blunt
sharp
Artery forceps, small (Spencer Wells)
Dissecting forceps
Ovum forceps (de Lee)
Vacuum aspirator
Kit for insertion of intrauterine contraceptive device Quantity Size Score
Metal sterilization tray, with cover
Bivalve speculum
small
medium
large
Sponge forceps
Long straight artery forceps
Uterine sound
Torch with batteries, or other suitable light source
Scissors
Antiseptic solution, aqueous iodine 1 in 2500
Benzalkonium chloride 1 in 75
IUD Quantity Size
IUD inserter
Sterile gloves
Vulsellum forceps
Dressing forceps
Metal bowl
Vulval pads
Total score
Percentage score %
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Element 225: Schedule for Planned maintenance of medical equipment is adhered to
RESP
ONS
IBLE PERSON A schedule for planned maintenance of medical equipment as per supplier specification must be available for all major equipment. A signed service level agreement between the supplier and hospital must be available. The planned maintenance schedule should be adhered
REVIEWER Request evidence of planned maintenance for medical equipment is adhered to.
There is no checklist for this element
NB Element 226: SOP for reactive maintenance of medical equipment is
available
RESP
ONS
IBLE PERSON The facility should have a standard operating procedure for the maintenance and repair of equipment that malfunctions prior to and after the planned maintenance. Make this SOP available to each service area.
REVIEWER Request to see a copy of the SOP for Reactive maintenance of medical equipment.
There is no checklist for this element
Element 227: Piped medical gas supply is maintained
RESP
ONS
IBLE PERSON Piped medical gas is essential for the emergency department, obstetrics and the theatre to be available. The facility must sign a SOP with a reliable company that will maintain and supply medical gas.
REVIEWERObtain a copy of the service level agreement with the gas supply company. Open and close the wall sockets to establish whether there is oxygen flow. Ask the professional nurses if supply was interrupted.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
CHECK IN THESE
FUNCTIONAL AREAS
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Element 228: Oxygen cylinders with oxygen gauge are available
RESP
ONS
IBLE PERSON The oxygen cylinders must be fitted with a functional oxygen gauge. The facility should have sufficient numbers of oxygen cylinders with the appropriate volume at all times. The facility must sign a SOP with a reliable company that will maintain and supply oxygen. Carry out Daily inspections to ensure sufficient volume of oxygen.
REVIEWERRequest to see a copy of daily oxygen cylinder volume assessment. Observe to see that each service area has oxygen cylinders with a functional gauge.
There is no checklist for this element
NB Element 229: Redundant and non-functional equipment are removed
from the hospital according to guidelines
RESP
ONS
IBLE PERSON The facility should follow the Provincial/District guidelines for removal of non-functional or redundant equipment. All asset disposal forms need to be completed and a condemnation certificate issued.
REVIEWERAssess the nature and number of items removed from the asset register. Review all the supporting documentation and availability of condemnation certificates. From the asset disposal register look whether these items were update in the asset register.
There is no checklist for this element
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Component 7: Infrastructure
Sub-component 29: ICT infrastructure and hardware
COMMITMENT FOR SUB-COMPONENT 29: Monitor whether systems for internal and external electronic communication are available and functional
Shared between the Systems Management but each service and operational area is required to be compliant
ELE
ME
NTS
230 There is 24 hour IT system support available
NB 231 There is a functional switchboard
232 There are functional telephones in all service and operational areas
NB 233 There is an emergency cellular phone available
NB 234 There are functional computers in all service and designated operational areas
NB 235 There are functional printers available in designated areas
NB 236 There is functional internet access in all service and designated operational areas
NB 237 There is intranet access on all computers
Vital Essential NB Important
Who is responsible for this sub-component?
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Element 230: There is 24 hour IT system support available
RESP
ONS
IBLE PERSON IT support must be available 24 hours a day seven days a week at the hospital. A schedule for the supporting employees should be displayed at the Executive Management offices and the Hospital switchboard for after-hour services.
REVIEWERRequest a copy of the IT services roster. Assess whether an after hour call roster is available.
There is no checklist for this element
NB Element 231: There is a functional switchboard
RESP
ONS
IBLE PERSON A switchboard that allows for incoming and outgoing calls must be available at the facility. The switchboard should be functional at all times. Sign a service learning agreement with a PABX supplier to supply, maintain and service the switchboard.
REVIEWERTo assess functionality, the reviewer should make an outgoing call from respective service areas. Use a cell phone and make an incoming call requesting the specific extension.
There is no checklist for this element
Element 232: There are functional telephones in all service and operational areas
RESP
ONS
IBLE PERSON Functional telephones must be available in all service and operational areas. Each service and operational area should be able to make internal calls and with relevant pin codes or authorisation external calls.
REVIEWERTo assess functionality, the reviewer must make an internal call within the hospital and request via the switchboard an external call.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 233: There is an emergency cellular phone available
RESP
ONS
IBLE PERSON
Enter into a hospital specific cellular contract with a service provider. The cellular phone should be available for emergency calls when the switchboard is out of service.
REVIEWERRequest to see the emergency cellular phone and assess whether there is sufficient airtime for making calls.
There is no checklist for this element
NB Element 234: There are functional computers in all service and
designated operational areas
RESP
ONS
IBLE PERSON
Each service area and designated operational area require a functional computer
REVIEWERTo assess functionality, the reviewer must switch the computer on and open a minimum of one program such as Microsoft Word.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 235: There are functional printers available in designated
areasRE
SPO
NSIBLE PERSON Functional printers linked to computers must be available in designated areas for
printing of discharge summaries and referral letters etc. The Printer maybe network shared. Sign a service level agreement with a competent service provider for supply, leasing and maintenance of printers at the facility.
REVIEWERTo assess functionality, the reviewer must type a letter or request the administrator in the service area to print a letter.
There is no checklist for this element
NB Element 236: There is functional internet access in all service and
designated operational areas
RESP
ONS
IBLE PERSON Internet access must be available in all service areas and designated operational areas. Sign a service level agreement with a competent service provider for internet access. Create a secure WIFI zone and if sufficient bandwidth is available open access to patients as well.
REVIEWERTo assess functionality, the reviewer must attempt to connect to the internet with the relevant password.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
NB
Element 237: There is intranet access on all computersRE
SPO
NSIBLE PERSON Intranet access must be available on all computers at the facility. Connect All computers
to the Local Area Network. Sign a service level agreement with a competent service provider for the Local Area Network.
REVIEWERTo assess the availability of intranet access the reviewer should open the Provincial and Hospital home pages and access information uploaded.
There is no checklist for this element
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Component 8: Operations Management
Sub-component 30: Hospital performance
COMMITMENT FOR SUB-COMPONENT 30: Monitor whether strategic and operational planning is conducted and the whether the key performance areas are monitored
The responsibility for this sub-component is with the Executive Management
ELE
ME
NTS
NB 238 Hospital has an approved 3-5 year strategic plan
NB 239 Quarterly performance reviews are conducted against the hospital annual operational plan
NB 240 Hospital management team track key performance indicators
NB 241 Hospital submits all monthly data on time to the next level
NB 242 There is quality improvement plan for non-clinical services
NB 243 A management meeting is held at least monthly
Vital Essential NB Important
NB Element 238: Hospital has an approved 3-5 year strategic plan
RESP
ONS
IBLE PERSON The hospital is required to develop a 3-5 year strategic plan. The strategic plan must be aligned to national DOH or provincial office priorities and considers stakeholder needs and local priorities. In addition the Strategic plans should reflect management responsibilities and accountabilities and detail targets for all action areas.
REVIEWERReviewer must obtain a copy of the strategic plan. Establish its time period and assess whether the plan was approved by the Hospital board and signed off by the Province.
There is no checklist for this element
Who is responsible for this sub-component?
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NB Element 239: Quarterly performance reviews are conducted against
the hospital annual operational planRE
SPO
NSIBLE PERSON
The hospital is required to develop and have an approved operational plan that provides for activities, outputs, responsibility, time frames and budget allocation. Quarterly review meetings by the executive management with the unit managers of the operational plan should be conducted and discuss targets and activities, Budget and expenditure (if relevant) Achievements, gaps and challenges, Resolutions/mitigating actions taken and Progress on resolutions taken on previous meetings.
REVIEWER
The reviewer should request presentations and reports from the quarterly review meetings.
There is no checklist for this element
There is no checklist for this element
NB Element 240: Hospital management team track key performance
indicators
RESP
ONS
IBLE PERSON The hospital management should receive reports for key performance indicators at minimum on a monthly basis. These performance indicators should be discussed during management meetings and areas of concerned should be addressed with specific interventions.
REVIEWERReviewer should obtain minutes of meeting and look for evidence that performance indicators in Checklist 240 have been discussed.
CHECKLIST FOR ELEMENT 240
HOSPITAL MANAGEMENT TEAM TRACK KEY PERFORMANCE INDICATORS
Description Score
Human Resources
Absenteeism
Staff vacancies
Turnover
RWOP
Financial and Systems Management
Supply chain and procurement
Priority Health Programmes
Infection Control
Pharmacy
Clinical effectiveness
Clinical risk
Quality assurance (waiting times, patient and staff satisfaction)
Risk Management
Total score
Total maximum possible score
Percentage score %
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NB Element 241: Hospital submits all monthly data on time to the next
level
RESP
ONS
IBLE PERSON The data generated by the hospital should be entered into the approved registers and data collection sheet. The data should be verified and analysed for presentation to the executive management. The data should be graphically displayed. The indicators should then be submitted to the next level on a monthly basis and signed off.
REVIEWERRequest the data submission form and verify dates of submission, acknowledgment of receipt of data and data sign off.
There is no checklist for this element
NB Element 242: There is quality improvement plan for non-clinical
services
RESP
ONS
IBLE PERSON A culture of continuous quality improvement needs to permeate throughout the facility. Non-clinical services are not exempt from continuous quality improvement. Quality improvement initiatives using an appropriate methodology such as PDSA cycle should be initiated to reduce variations and any potential defects.
REVIEWERRequest documentation pertaining to all quality improvement initiatives. These reports should contain a baseline analysis, identification of variation/defect, root cause analysis, implementation of intervention and evaluation of the intervention. The quality improvement reports for the areas identified in Checklist 242 should be evaluated.
CHECKLIST FOR ELEMENT 242
THERE US A QUALITY IMPROVEMENT PLAN FOR NON-CLINICAL SERVICES
Description Score
CSSD
Food Services
Linen
Security
Total score
Total maximum possible score
Percentage score %
NB Element 243: A management meeting is held at least monthly
RESP
ONS
IBLE PERSON The hospital executive management team must convene a monthly meeting. The aim of the meeting should be to provide feedback on issues pertaining to their relative disciplines as well as discuss impending changes as well as budgetary considerations
REVIEWERThe calendar for management meeting should be reviewed and minutes of meeting should provide evidence for monthly meetings.
There is no checklist for this element
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Component 8: Operations Management
Sub-component 31: Management of patient experience of care
COMMITMENT FOR SUB-COMPONENT 31: Monitor whether an annual patient experience of care survey is conducted and whether patients are provided with an opportunity to complain about or compliment the hospital and whether complaints are managed within the prescribed time
The responsibility for this sub-component is with the Executive Management
ELE
ME
NTS
244 National Patient Experience of Care Guideline is available
245 Results of the annual Patient Experience of Care Survey are visibly displayed at main reception
246 An average overall score of 80% is obtained in the Patient Experience Of Care Survey
247 The National Guideline to Manage Complaints/Compliments/Suggestions is available
248 Complaints/compliments/suggestions tool kit is available
249 Complaints/compliments/suggestions Records show compliance to the National Guideline to Manage Complaints/Compliments/Suggestions
250 Targets set for complaint indicators are met
251 National Policy for the Management of Waiting Times is available
252 Patients are informed of Hospital waiting times for designated services
NB 253 Waiting times are monitored for ambulatory and other designated service areas
Vital Essential NB Important
Who is responsible for this sub-component?
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Element 244: National Patient Experience of Care Guideline is available
RESP
ONS
IBLE PERSON Ensure that the hospital has the National Patient Experience of Care Guideline- downloaded from www.doh.gov.za
REVIEWERVerify that the hospital has a copy of the National Patient Experience of Care Guideline.
There is no checklist for this element
Element 245: Results of the annual Patient Experience of Care Survey are visibly displayed at main reception
RESP
ONS
IBLE PERSON The Patient Experience of Care Survey should be conducted in conformance with the guidelines. The data obtained should be analysed and either displayed as a Table or Graph in the main reception
REVIEWERObserve whether the results of the last Patient Experience Survey is displayed in the main reception areas.
There is no checklist for this element
Element 246: An average overall score of 80% is obtained in the Patient Experience of Care Survey
RESP
ONS
IBLE PERSON
The overall mean score across all the six components should be 80% or more.
REVIEWERVerify the results of the patient experience survey and check that the overll average score is 80% or more.
There is no checklist for this element
Element 247: The National Guideline to Manage Complaints, Compliments and Suggestions is available
RESP
ONS
IBLE PERSON Ensure that the hospital has an electronic or hard copy of the National Guideline to Manage Complaints, Compliments and suggestions should be downloaded from www.doh.gov.za. The facility should familiarise itself with the requirements.
REVIEWERVerify that the facility has a copy of the National Guideline to Manage Complaints, Compliments and suggestions.
There is no checklist for this element
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Element 248: Complaints/compliments/suggestions tool kit is available
RESP
ONS
IBLE PERSON
A complaints, compliments, suggestion box according to National specifications should be placed at a visible and accessible location at the entrance and or exit of the facility. The National poster that describes the process for lodging complaints/compliments/suggestion must be visibly display in at least two local languages at the main entrance/exit of the facility next to the complaints/compliments/suggestion box. A pen and sufficient copies of the complaints, compliments and suggestions forms must be available from the person managing complaints, compliments and suggestions or next to the box.
REVIEWER
Observe whether The National poster that describes the process for lodging complaints/compliments/suggestion is visibly display in at least two local languages at the main entrance/exit of the facility next to the complaints/compliments/suggestion box; a pen and sufficient copies of the complaints, compliments and suggestions forms must be available next to the box.
There is no checklist for this element
Element 249: Complaints/compliments/suggestions Records show compliance to the National Guideline to Manage Complaints/Compliments/Suggestions
RESP
ONS
IBLE PERSON
The facility needs to develop a standard operating procedure for using the National Guideline for Developing a Facility Specific SOP to Manage Complaints, Compliments and Suggestions. A staff member usually the Quality Assurance Manager or the Public Relations Officer should be designated to ensure compliance with the facility’s SOP to manage complaints, compliments and suggestions. The facility should capture the information from the complaints/compliment/suggestion form on the national web-based information system for Complaints/compliments/suggestions. The following records should be kept at the facility: letters of complaint and the redress letters and/or minutes of redress meeting. At the end of every month statistical data on complaints, compliments and suggestions and categories of complaints should be generated. Add to the facility’s quality improvement plans areas where gaps have been identified. These should be incorporated in the facility quality improvement plan.
REVIEWERThe reviewer should assess compliance to this element by requesting a copy of the facility SOP to manage complaints, compliments and suggestions. Five complaints letters as well as five redress letters or minutes of meetings should be reviewed. The complaints, compliments, suggestion register as well as the statistical data should be reviewed to assess compliance with the SOP.
CHECKLIST FOR ELEMENT 249
COMPLAINTS/COMPLIMENTS/SUGGESTIONS RECORDS SHOW COMPLIANCE TO THE NATIONAL GUIDELINE TO MANAGE COMPLAINTS/COMPLIMENTS/SUGGESTIONS
Item Score
The facility’s/district’s Standard Operating Procedure to Manage Complaints/Compliments/Suggestions is available
Complaints letters (check the last 5 complaints resolved)
Complaints redress letters/minutes (check the last 5 complaints resolved)
Complaints register
Compliments register
Suggestion register
Statistical data on classifications of complaints
Statistical data on indicators for complaints, compliments and suggestions
Total score
Percentage score %
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Element 250: Targets set for complaint indicators are met
RESP
ONS
IBLE PERSON The facility should resolve all complaints with appropriate redress. The target is that 90% of all complaints should be resolved and 90% of the total complaints should be resolved within 25 days.
REVIEWER
Assess, from the register, that the indicators have been achieved.
CHECKLIST FOR ELEMENT 250
TARGETS SET FOR COMPLAINT INDICATORS ARE MET
Description Score
90% of complaints are resolved
90% of complaints are resolved within 25 days
Total score
Percentage score %
NB Element 251: National Policy for the Management of Waiting Times is
available
RESP
ONS
IBLE PERSON
Ensure the The National Policy for the Management of Waiting Times is available either as a hard copy of electronic copy- from www.doh.gov.za
REVIEWERVerify that the hospital has a copy of the National Policy for the Management of Waiting Times.
There is no checklist for this element
Element 252: Patients are informed of Hospital waiting times for designated services
RESP
ONS
IBLE PERSON The waiting times should be visibly displayed at the reception and waiting areas of the facility for emergency services, ambulatory services, health support services, radiology and pharmacy services
REVIEWERObserve whether the waiting times are displayed at the reception and waiting areas for emergency services, ambulatory services, health support services, radiology and pharmacy services.
There is no checklist for this element
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NB Element 253: Waiting times are monitored for ambulatory and other
designated service areasRE
SPO
NSIBLE PERSON
The waiting time should be monitored on a quarterly basis using the prescribed National waiting time tool. A pre-determined date should be established to monitor the patients waiting time. The 1st 100 patients irrespective of the diagnosis should be tracked for all the services that were rendered to the patient on that date across all service areas. The waiting time tool should be attached to the patient’s record and completed. The data should be analysed by the facility information officer and a report generated.
REVIEWERRequest a copy of the report for the latest patient waiting time survey. The report should include all ambulatory and designated service areas.
There is no checklist for this element
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Radiology
Pharmacy
Laboratory
CHECK IN THESE
FUNCTIONAL AREAS
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Component 8: Operations management
Sub-component 32: Finance and systems
COMMITMENT FOR SUB-COMPONENT 32: Monitor the consistent availability of a functional supply chain management system, as well as the availability of funds required for optimal service provision
Financial Management and Supply chain management
ELE
ME
NTS
NB 254 The Public Finance Management Act is adhered to
NB 255 Hospital has an annual financial plan aligned to allocated budget
NB 256 Monthly projection and expenditure reports from BAS are available
257 100% of suppliers paid within 30 days from date of invoice received
258 Goods and Services are procured in accordance to Supply Chain procedures
NB 259 LOGIS reports are used to track purchases and receipts
NB 260 100% of Goods and Services received are in compliance with specifications
NB 261 An up to date asset register is available
NB 262 Condemned equipment are removed according to guidelines’
NB 263 SOP for stock management is adhered to
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 254: The Public Finance Management Act is adhered to
RESP
ONS
IBLE PERSON
The Public Finance and Management Act regulates the management of finances and sets out the procedures for efficient and effective management of all revenue, expenditure, assets and liabilities. It establishes the duties and responsibilities of government officials in charge of finances. This act is available at www.treasury.gov.zaThe Public Finance and Management Act (PFMA) requires that the delegation of authority is through a formal letter provided to the Accounting officer. In addition, the PFMA provides guidelines for the management of wasteful and fruitless expenditure.
REVIEWERThe delegation of authority letter and the mandate must be inspected. Conduct an audit of the process of managing financial misconduct in order to assess compliance .
CHECKLIST FOR ELEMENT 254
THE PUBLIC FINANCE MANAGEMENT ACT IS ADHERED TO
Description ScoreDelegation of authority for the hospital CEO is adhered to
Financial misconduct is managed in line with the PFMA
Total score
Total maximum possible score
Percentage score %
NB Element 255: Hospital has an annual financial plan aligned to
allocated budget
RESP
ONS
IBLE PERSON The hospital will prepare an annual budget and submit to the District for inclusion in District Health Plan or to the Province of a regional or tertiary hospital. On receipt of the final hospital allocation, a financial plan needs to be developed.
REVIEWER Request a copy of the financial plan related to the allocated budget.
There is no checklist for this element
NB Element 256: Monthly projection and expenditure reports from BAS
are available
RESP
ONS
IBLE PERSON The Basic Accounting System (BAS) is the financial management system used to forecast and track expenditure within the institution. The hospital must generate monthly forecast and expenditure reports that are discussed at Management meetings
REVIEWER Request copies of monthly forecast and expenditure reports.
There is no checklist for this element
NB
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Element 257: 100% of suppliers paid within 30 days from date of invoice received
RESP
ONS
IBLE PERSON
The Government is committed to ensure that all suppliers receive payment within 30 days of receipt of an invoice.
REVIEWER The order book, payment uploading documentation and proof of payment must be analyzed to assess whether payment has been completed within the stipulated period.
There is no checklist for this element
Element 258: Goods and Services are procured in accordance to Supply Chain procedures
RESP
ONS
IBLE PERSON
The facility needs to procure goods and services in line with Provincial treasury guidelines. The Provincial Supply chain procedures should be available at the facility.
REVIEWER
Interview the supply chain manager and view documentary proof of selected procured items from different cost values.
There is no checklist for this element
CHECKLIST FOR ELEMENT 258
GOODS AND SERVICES ARE PROCURED IN ACCORDANCE TO SUPPLY CHAIN PROCEDURES
Goods and Services are procured in accordance to Supply Chain procedures Score
Procurement plans indicate what purchases an institution will undertake in the short, medium and long-term
Standards and specification for goods to be procured are available
Requests for quotations exceeding R30 000 must comply with the provisions of the PPPFA
Bid adjudicating committee is constituted
Minutes of bid committee is available
Total score
Total maximum possible score
Percentage score %
NB Element 259: LOGIS reports are used to track purchases and receipts
RESP
ONS
IBLE PERSON
The LOGIS system is the Government wide enterprise system used for supply chain processes. The LOGIS system must be used for tracking purchases and receipts.
REVIEWER Assess a print out of the last months LOGIS activities to determine compliance.
There is no checklist for this element
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NB Element 260: 100% of Goods and Services received are in compliance
with specificationsRE
SPO
NSIBLE PERSON Specifications must be developed for all goods and services that are procured. These
specifications could be facility developed or be based on Provincial or National specifications. The receiving /procurement clerk should assess all goods and services for compliance.
REVIEWERThe receipt book for goods and services should be analysed to assess whether all goods and services were in line to specifications.
There is no checklist for this element
NB Element 261: An up to date asset register is available
RESP
ONS
IBLE PERSON
The facility must maintain an updated asset register for all furniture and equipment available at the facility. This asset register must be updated on a monthly basis.
REVIEWER Select three random furniture items and medical equipment items and verify that they are present in asset register and service areas. Use Checklist 261 for assessing compliance.
CHECKLIST FOR ELEMENT 261
AN UP TO DATE ASSET REGISTER IS AVAILABLE
Description Score
Select three furniture items the asset register and verify that each is present in the service area
Select three furniture items from the service areas and verify that each is present in the asset register
Select three medical equipment items the asset register and verify that each is present in the service area
Select three medical equipment items from the service areas and verify that each is present in the asset register
Total score
Percentage (Total score ÷ 6) x 100 %
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NB Element 262: Condemned equipment are removed according to
guidelines
RESP
ONS
IBLE PERSON The provincial guidelines for condemned equipment should be available at the facility. The facility should adhere to the guidelines for condemned equipment.
REVIEWERReview: The reviewer should request a certificate of condemnation for the last six months, assess the asset disposal register and observe where the condemned equipment is stored.
CHECKLIST FOR ELEMENT 262
CONDEMNED EQUIPMENT ARE REMOVED ACCORDING TO GUIDELINES’
Description Score
Certificate for condemned equipment is available for the last six months
Asset disposal register must contain the following:
Item description
Plan disposal date
Disposal method
Condemed equipment must be kept in secure location prior to disposal
Total score
Percentage (Total score ÷ 6) x 100 %
NB Element 263: SOP for stock management is adhered to
RESP
ONS
IBLE PERSON Establish a facility specific SOP for the management of stock. The SOP must stipulate turnaround times for critical stock; determination of minimum and maximum stock levels and re-order levels; stock take annually and storage of stock.
REVIEWER The reviewer must request documentation as well as conduct an inspection. Use the Checklist to assess compliance.
CHECKLIST FOR ELEMENT 263
SOP FOR STOCK MANAGEMENT IS ADHERED TO
Description Score
The terms of agreement for the supply of stock is available
Turnaround times for critical stock are monitored
Stock is stored in a bulk storage facility
Minimum and maximum stock levels and re-order levels are stipulated
Stock take of supplies is done annually
Total score
Percentage (Total score ÷ 5) x 100 %
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Component 8: Operations Management
Sub-component 33: Fleet Management
COMMITMENT FOR SUB-COMPONENT 33: Monitor the appropriate use and maintenance of hospital vehicle fleet
Systems Management
ELE
ME
NTS NB 264 Planned Maintenance for hospital vehicles is adhered to
NB 265 Vehicle management system is in place
Vital Essential NB Important
NB Element 264: Planned maintenance for hospital vehicles is adhered to
RESP
ONS
IBLE PERSON Each vehicle requires planned maintenance as per the manufacturer’s specification at interval of 15000 or 20000 kilometres. It is important that these intervals be adhered to.
REVIEWER Assess the service records books for frequency of planned maintenance services.
There is no checklist for this element
Who is responsible for this sub-component?
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NB Element 265: Vehicle management system is in place
RESP
ONS
IBLE PERSON Each facility must have a vehicle management system that includes copies of the maintenance schedule, vehicle licences, driver’s licences and professional permits, log sheets and fuel expenses.
REVIEWERRequest documentation or files for the vehicle management system as per the checklist
CHECKLIST FOR ELEMENT 265
A VEHICLE MANAGEMENT SYSTEM IS IN PLACE
Description Score
There is a maintenance schedule for all vehicles
There is a valid licence available for each vehicle
There is a copy of a valid driver’s licence and professional driver’s permit for each driver
There is a log sheet for each vehicle
There is a fuel consumption record for each vehicle
Total score
Percentage (Total score ÷ 5) x 100 %
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Component 8: Operations Management
Sub-component 34: Communication
COMMITMENT FOR SUB-COMPONENT 34: Monitor whether there are appropriate systems for communicating with internal and external stakeholders.
Executive Management
ELE
ME
NTS
NB 266 Relevant information sharing is done with internal stakeholders using appropriate media platforms monthly
NB 267 Relevant information sharing is done with the community using community based platforms
NB 268 Hospital observes annual health calendar days
Vital Essential NB Important
NB Element 266: Relevant information sharing is done with internal
stakeholders using appropriate media platforms monthly
RESP
ONS
IBLE PERSON It is important for staff to have information regarding achievements and other facility based activities. The facility should update its internal website, have a monthly newsletter, or use social media and/or display messages at staff meeting or resting points.
REVIEWERLook for evidence of communication sharing through newsletters, websites or social media platforms.
There is no checklist for this element
NB Element 267: Relevant information sharing is done with the
community using community based platforms
RESP
ONS
IBLE PERSON The community are important stakeholders for the facility and it is important that relevant information is communicated that will be beneficial to them using community based newspapers, imbizo’s and local radio stations.
REVIEWERLook for evidence of communication sharing through community based newspapers, imbizo’s and local radio stations.
There is no checklist for this element
Who is responsible for this sub-component?
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NB Element 268: Hospital observes annual health calendar days
RESP
ONS
IBLE PERSON The facility must obtain a list of health awareness days from the National Department of Health. The Public relation officer and relevant clinical service providers must plan information sharing sessions for the calendar days.
REVIEWERLook for evidence of that information sharing for annual health awareness days were conducted.
There is no checklist for this element
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Component 8: Operations Management
Sub-component 35: Management Information Systems
COMMITMENT FOR SUB-COMPONENT 35: Monitor whether there is an appropriate information system that produces information for service planning and decision-making.
Shared by the Hospital Corporate Services (Executive Management, Systems Management, Supply Chain Management, Administration and Reception
Services, Finance and Human Resources Management)
ELE
ME
NTS
NB 269 National District Health Management Information System policy is adhered to
NB 270 There is a functional electronic patient registration system
NB 271 ICD 10 coding is utilised
NB 272 There is an up to date electronic human resource management information system (PERSAL)
NB 273 There is an up to date financial management information system (BAS)
NB 274 There is an up to date procurement management information system (LOGIS)
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 269: National District Health Management Information
System policy is adhered to
RESP
ONS
IBLE PERSON
The facility should obtain a copy of the National District Health Management Information System policy from www.doh.gov.za. A facility specific standard operating procedure for the collection, capturing, analysis and reporting of the Hospital specific dataset must be developed. Data must be submitted monthly and timeously to the District or Province.
REVIEWER The Reviewer must request documentary evidence for the National Distritc Health Management Information system; Facility DHMIS SOP and minimum dataset. The reviewer must assess whether the DHIS registers are completed and whether data is submitted on time. Interview the FIO and ask whether any training was provided.
CHECKLIST FOR ELEMENT 269
NATIONAL DISTRICT HEALTH MANAGEMENT INFORMATION SYSTEM POLICY IS ADHERED TO
Description Score
National District Health Management Information System policy is available
Facility level DHMIS SOP is available
National and Provincial Information Indicator Data Set for Hospitals is available
Relevant DHIS registers are completed
FIO submits all monthly data to CEO for approval on time
Hospital information officer and data capturer’s trained on the hospital level Guidelines for Data Management
Total score
Total maximum possible score (sum of all scores minus the NA)
Percentage (Total score ÷ Total maximum possible score) x 100 %
NB Element 270: There is a functional electronic patient registration
system
RESP
ONS
IBLE PERSON All patients attending the facility must be recorded on the Health Patient Repository System so that a central database is created for all patients accessing public health facilities.
REVIEWER
Request to see evidence of patients registered on the electronic system and the system is functional.
There is no checklist for this element
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NB Element 271: ICD 10 coding is utilised
RESP
ONS
IBLE PERSON
ICD 10 diagnostic classification should be used for all patients consulted at the facility.
REVIEWERThe discharging records should be assessed to application of ICD 10 codes.
There is no checklist for this element
NB Element 272: There is an up to date electronic human resource
management information system (PERSAL)
RESP
ONS
IBLE PERSON The PERSAL system is the National Human Resource System utilised in South Africa. All personnel employed within health facilities must have their details entered within the system and have PERSAL numbers.
REVIEWERRequest the human resource officers to produce evidence that the system has been updated to the last calendar month prior to assessment.
There is no checklist for this element
NB Element 273: There is an up to date financial management
information system (BAS)
RESP
ONS
IBLE PERSON The BAS system is used to capture financial transactions across all facilities in South Africa. All financial transactions of the health facilities must be recorded in BAS.
REVIEWERRequest the financial officers to produce evidence that the system has been updated to the last calendar month prior to assessment.
There is no checklist for this element
NB Element 274: There is an up to date procurement management
information system (LOGIS)
RESP
ONS
IBLE PERSON The LOGIS system is used to record all items procured at health facilities in South Africa. All goods and services procured at the facilities must be recorded on the LOGIS.
REVIEWER
Request the supply chain management officers to produce evidence that the system has been updated to the last calendar month prior to assessment.
There is no checklist for this element
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Component 8: Operations Management
Sub-component 36: Emergency Medical Services and planned patient transport
COMMITMENT FOR SUB-COMPONENT 36: Monitor the effectiveness of emergency responses and planned patient transport
Administration/Reception Services
ELE
ME
NTS
NB 275 Emergency contact numbers (fire, police, ambulance) are displayed in all service and operational areas
NB 276 EMS available for priority maternity transfers
NB 277 EMS available for emergency inter-facility transfer
NB 278 EMS response complies with the pre-determined response time
NB 279 There is a schedule for planned patient transport
NB 280 Planned patient transport is provided according to schedule
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 275: Emergency contact numbers (fire, police, ambulance)
are displayed in all service and operational areasRE
SPO
NSIBLE PERSON
Display Emergency contact numbers in all service and operational areas. The numbers should include:
• Fire: Obtain this number from the local municipality
• Police: The National Emergency number 10111 and the local police station number
• Ambulance Services: 10177, 112, or the local base unit number
REVIEWERObserve that the emergency numbers are displayed in all service and operational areas.
There is no checklist for this element
NB Element 276: EMS available for priority maternity transfers
RESP
ONS
IBLE PERSON
Maternal Obstetric Ambulances that are full equipped and have the appropriate category of human resources should be available within the District.
REVIEWERAsk the nursing manager in the maternity unit about access to ambulances for priority maternal transfers.
There is no checklist for this element
NB Element 277: EMS available for emergency inter-facility transfer
RESP
ONS
IBLE PERSON
EMS Transport should be accessible and available for emergency inter-facility transfer.
REVIEWERAsk the emergency department physicians about access to ambulances for priority maternal transfers.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 278: EMS response complies with the pre-determined
response time
RESP
ONS
IBLE PERSON
Obtain the norm for the EMS response time from the Provincial/District EMS service manager. At the facility the staff member requesting patient emergency transport must record the patient name, date and time patient transport was requested, referral destination, and date and time of patient collection in the ambulance response time. On a monthly basis, monitor the trend in response time to determine whether the EMS complies with the norm.
REVIEWER Request the facility for reports on EMS response times for the past quarter.
There is no checklist for this element
NB Element 279: There is a schedule for planned patient transport
RESP
ONS
IBLE PERSON The district emergency medical services in consultation with the District management team should develop an annual schedule for planned patient transport. The planned patient transport schedule must be available and displayed at all clinical service areas as well as the transport booking office.
REVIEWER Request for the planned patient transport schedule for the current calendar year.
There is no checklist for this element
NB Element 280: Planned patient transport is provided according to
schedule
RESP
ONS
IBLE PERSON Maintain a register that details the name of the patients scheduled for planned patient transport services in the booking office. This register should include details of whether the patient were transported on the scheduled date and reasons if not transported in terms of the schedule.
REVIEWER Request for the planned patient transport register for the current calendar year and review if the service is offered per schedule.
There is no checklist for this element
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Component 8: Operations Management
Sub-component 37: Disaster and emergency preparedness
COMMITMENT FOR SUB-COMPONENT 37: Monitor whether the hospital is equipped and prepared for management of internal and external disaster
The responsibility for this sub-component is with the Executive Management but each service and operational area is required to be compliant
ELE
ME
NTS
NB 281 There is an inter-sectoral plan for the management of possible health emergencies and disease outbreaks
NB 282 Disaster management plan is available
NB 283 Contact numbers required in emergencies are available in designated areas
NB 284 A drill for a mass casualty incident is conducted annually
NB 285 An improvement plan is developed based on the results of the mass casualty drill
NB 286 Emergency evacuation plan is displayed in all areas
NB 287 Emergency evacuation drill is practised annually
NB 288 All emergency exits and entrance points are kept clear at all times
NB 289 An improvement plan is developed to address the results of the emergency evacuation drill
NB 290 Functional firefighting equipment is available
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 281: There is an inter-sectoral plan for the management of
possible health emergencies and disease outbreaks
RESP
ONS
IBLE PERSON At a district/Provincial level an inter-sectoral plan for management of possible health emergencies and disease outbreaks should be available. The hospital will be an integral part of this plan. A copy of the plan must be available at the hospital
REVIEWER Request the executive management team to provide a copy of the inter-sectoral plan.
There is no checklist for this element
NB Element 282: Disaster management plan is available
RESP
ONS
IBLE PERSON The internal and external risks with catastrophic implications must be identified at a hospital. A disaster management plan must be developed and should be available in all service areas.
REVIEWERRequest to see a copy of the Latest Disaster Management Plan. Ensure that the plan has been reviewed.
There is no checklist for this element
NB Element 283: designated areas
RESP
ONS
IBLE PERSON
The contact details for the required personnel in emergencies must be available in all service and operational areas. This will include amongst others:
• District outbreak team• District Manager• Hospital Manager• Emergency clinicians• Referring Hospital• Relevant professional staff
REVIEWERObserve to see whether contact numbers required are available in all the areas listed below.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 284: A drill for a mass casualty incident is conducted
annuallyRE
SPO
NSIBLE PERSON
Conduct an annual mass casualty incident drill at the hospital. The date should be pre-determined. On the date and time, make an announcement of the mass casualty incident in line with the standard operating procedures. Implement the plan. A report should be compiled highlighting strengths, challenges and recommendations for improvement.
REVIEWER Request to see a copy of the annual mass casualty incident drill report.
There is no checklist for this element
NB Element 285: An improvement plan is developed based on the results
of the mass casualty drill
RESP
ONS
IBLE PERSON
Develop an improvement plan emanating from the mass casualty incident drill. Implement the remedial actions within two weeks.
REVIEWERRequest a copy of the improvement plan that addresses the deficiencies identified in the drill.
There is no checklist for this element
NB Element 286: Emergency evacuation plan is displayed in all areas
RESP
ONS
IBLE PERSON
Develop an emergency evacuation plan as part of the risk management process. Graphically display the emergency evacuation plan in all service and operational areas.
REVIEWERObserve that the emergency evacuation plan is graphically displayed in all service areas.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 287: Emergency evacuation drill is practised annually
RESP
ONS
IBLE PERSON
Conduct an emergency evacuation drill at the hospital. The date should be pre-determined. On the date and time, Sound the relevant announcement or alarm alerting the staff and patient of the emergency in line with the standard operating procedures. Implement the plan. A report should be compiled highlighting strengths, challenges and recommendations for improvement.
REVIEWER Request to see a copy of the emergency evacuation drill report.
There is no checklist for this element
NB Element 288: All emergency exits and entrance points are kept clear
at all times
RESP
ONS
IBLE PERSON
Emergency exits and entrances need to be clearly marked with appropriate signage directions. The Emergency exits and entrances should be obstruction free.
REVIEWERObserve that the emergency exits and entrances are obstruction free (No boxes or equipment etc. are placed in the pathway).
There is no checklist for this element
NB Element 289: An improvement plan is developed based on the results
of the Emergency evacuation drill
RESP
ONS
IBLE PERSON
Develop an improvement plan emanating from the emergency evacuation drill. Implement the remedial actions within two weeks.
REVIEWER Request a copy of the improvement plan.
There is no checklist for this element
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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NB Element 290: Functional firefighting equipment is available
RESP
ONS
IBLE PERSON Sign a service level agreement with a competent service provider for the supply and maintenance of firefighting equipment. Carry out an annual maintenance on the equipment and record the date of service.
REVIEWERObserve whether functional fire extinguishers and fire hoses and reels are available in all service and operational areas and have been maintained.
CHECKLIST FOR ELEMENT 290
FUNCTIONAL FIREFIGHTING EQUIPMENT IS AVAILABLE
Description Score
Fire extinguishers are available
Fire hoses and reels unless it is a single-storey building of less than 250 m2 in floor area
Firefighting equipment is maintained according to schedule
Total score
Percentage score %
Accident & Emergency unit
Obstetrics unit
Paediatric ward
Maternity ward
Nursery
Medical ward
Surgical ward
Intensive Care/High Care
Theatre
Ambulatory health services (acute, chronic, obstetric)
Physiotherapy
Occupational therapy
Nutritional support (dietetics)
Oral Health Services
Speech therapy
Social work
Eye health
Podiatry
Audiology
Medical orthotics and prosthetics
Rehabilitative and Palliative Care
Radiology
Pharmacy
Laboratory
Food Services
CSSD
Laundry
Mortuary
Executive management
Administration/reception services
Systems management
Supply chain management
Financial management
Human resource management
Infrastructure
CHECK IN THESE
FUNCTIONAL AREAS
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Component 9: Governance
Sub-component 38: Stakeholder engagement and management
COMMITMENT FOR SUB-COMPONENT 38: Monitor the functionality of the stakeholder engagement
The responsibility for Sub-component is with the Executive Management.
ELE
ME
NTS
NB 291 There is a formal agreement in-place between the hospital and various government departments
NB 292 There is a functional Hospital Board
NB 293 There is a forum established to engage with health-related stakeholders
NB 294 Hospital has an annual open day
Vital Essential NB Important
Who is responsible for this sub-component?
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NB Element 291: There is a formal agreement in-place between the
hospital and various government departments
• The Provincial Department of Health should develop formal agreements between various governments departments as listed in Checklist 291.
• The responsibilities of both the Department of Health and the listed Government department should be clearly articulated.
• A copy of the signed agreement should be available at the facility
• Staff need to be oriented about the nature and terms formal agreement
• Reports on how these agreements are functioning need to be presented to the District/ Provincial Department
CHECKLIST FOR ELEMENT 291
THERE IS A FORMAL AGREEMENT IN-PLACE BETWEEN THE HOSPITAL AND VARIOUS GOVERNMENT DEPARTMENTS
Description Score
There is an official memorandum of understanding between the PDOH and Correctional Services
There is an official memorandum of understanding between the PDOH Department of Education
There is an official memorandum of understanding between the PDOH and Department of Home Affiars
There is an official memorandum of understanding between the PDOH and the Department of Social Development
There is an official memorandum of understanding between the PDOH and Department of Public Works
There is an official memorandum of understanding between the PDOH and Department of Transport
There is an official memorandum of understanding between the PDOH and SAPS
Total score
Percentage score %
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NB Element 292: There is a functional Hospital Board
RESP
ONS
IBLE PERSON Hospital Boards are an important Governance Structure and are mandated in terms of the National Health Act. The Provincial Department of Health is responsible for the appointment of Hospital Boards.
REVIEWER In assessing compliance, the reviewer should assess the nomination process, formal appointment, training, functioning of the hospital board, management of community complaints accountability and communication (Checklist 292).
CHECKLIST FOR ELEMENT 292
THERE IS A FUNCTIONAL HOSPITAL BOARD
Nomination process Score
Agenda
Attendance register
Hospital Committee guidelines
Copy of submission to the sub-district
Formal Appointment
Signed appointment letters from Office of the MEC or delegated person
Adopted and signed constitution as per provincial guidelines (Terms of Reference)
Code of conduct for Hospital Committee
Training
Attendance register for orientation and training conducted in the past 12 months
Services Planning, Monitoring, Evaluation and meetings
List of community needs as determined by the Hospital Committee in past 12 months
Agendas indicating that community needs and progress against operation plan was discussed at least twice in the past 12 months
Signed minutes indicating that the Hospital Committee was informed on the progress against the facility’s operational plan at least twice in the past 12 months
Current year plan indicating the scheduled meetings (at least two within the next 12 months)
Attendance registers shows that meetings held formed a quorum
Minutes of Hospital Board meetings indicate that statistical data on population health indicators are discussed
Minutes of Hospital Committee meetings indicate that the clinic’s human resources situation is discussed
Minutes of Hospital Board meetings indicate that situation relating to equipment and, supplies is discussed
Complaints, Compliments and Suggestion Management (check record of the past 6 months)
Proof that Hospital Committee took part in opening of complaints boxes according to stipulated schedule (signed register)
Minutes indicate that the management of complaints, compliments and suggestions are discussed at Hospital Committee meetings
Accountability and Communication
Contact details of Hospital Board members visibly displayed in reception area
Minutes of the Ward Committee meeting indicate that a member of the Hospital Board gave feedback at the Ward Committee meeting on health-related matters
Total score
Percentage score %
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NB Element 293: There is a forum established to engage with health-
related stakeholdersRE
SPO
NSIBLE PERSON
The hospital must obtain a list of implementing partners, internal stakeholders, external stakeholders and non-governmental organisation that are operating in the district. The list must include their focus and business activities.
The district schedules an annual meeting with all identified health partners to discuss and agree on their contribution to support the facility.
REVIEWERVerify that a list of all internal and external stakeholders has been compiled. Obtain evidence of meetings scheduled with stakeholders (Checklist 293).
CHECKLIST FOR ELEMENT 293
THERE IS FORUM ESTABLISHED TO ENGAGE WITH HEALTH-RELATED STAKEHOLDERS
Description Score
Internal stakeholders identified
External stakeholders
Non-governmental organisations
Total score
Percentage score %
NB Element 294: Hospital has an annual open day
RESP
ONS
IBLE PERSON In consultation with facility staff and community leaders the hospital need to plan for open days. These activities include screening and health promotion. A calendar for these open days should be available.
REVIEWER
There is no checklist for this element
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Component 9: Governance
Sub-component 39: Audit compliance and risk management
COMMITMENT FOR SUB-COMPONENT 39: Monitor and review effectiveness of risk prevention and mitigation strategies.
Shared between the Executive Management, Systems Management and Financial Management
ELE
ME
NTS
295 Hospital has functional audit and risk committees
296 A contract management system is in place
297 Hospital specific risks are identified
NB 298 Risk management plan is available
NB 299 Risk mitigation strategies are implemented
300 Hospital receives a clean audit report from the Auditor General
Vital Essential NB Important
Who is responsible for this sub-component?
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Element 295: Hospital has functional audit and risk committeesRE
SPO
NSIBLE PERSON The CEO of the hospital is responsible for appointment of an audit and risk committee
in terms of the Public Finance Management Act. The audit committee should have terms of reference that need to be reviewed annually.
REVIEWERRequest for the minutes of meetings and reports produced by the audit and risk committee.
CHECKLIST FOR ELEMENT 295
HOSPITAL HAS FUNCTIONAL AUDIT AND RISK COMMITTEES
Description Score
Unauthorised, Irregular, Wasteful and Fruitless Expenditure Registers/Reports
Monthly Transaction summary report
Monthly unclear accounts report
Segregation of functions (Requisition, Verifications, Capturing, Payment)
Independent Reconciliations of Expenditures including Petty Cash
Access to verifiable source documents incl. face value vouchers e.g. Invoices
Security of verifiable source documents
Minutes of Audit and risk committee meetings available
Total score
Percentage score %
Element 295: A contract management system is in place
RESP
ONS
IBLE PERSON The financial manager of the hospital should establish a system for managing contracts. Records of the various contracts should be maintained, with the designated managers monitoring the implementation of the contracts on a monthly basis and implementing remedial actions if necessary.
REVIEWERObtain records of the contract, evidence of monthly monitoring of the contracts and remedial actions taken if necessary.
CHECKLIST FOR ELEMENT 296
A CONTRACT MANAGEMENT SYSTEM IS IN PLACE
Description Score
Records for contracts for various services are maintained (eg. Waste, laundry, food)
Contract are monitored by the relevant designated service manager
Contracts are monitored monthly
Remedial action is implemented when variances are identified
Total score
Percentage score %
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Element 297: Hospital specific risks are identified
Each hospital should maintain a risk register. In terms of identification, the register should include the following information
Date Risk identified or modified Describe the risk Risk type/area:
business, clinical Risk rating Severity in terms of impact
Request to see the risk register and verify that all risk are identified and classified.
NB Element 298: Risk management plan is available
Assess whether a risk mitigation plan has been developed for each risk
Countermeasures: to prevent, reduce or transfer Responsibility for addressing
risks
Status: current risk or no longer a
problemCost
NB Element 299: Risk mitigation strategies are implemented
RESP
ONS
IBLE PERSON
The hospital is required to investigate and maintain a register for any loss or theft.
REVIEWER
Request to see the risk register and findings of relevant investigations.
CHECKLIST FOR ELEMENT 299
RISK MITIGATION STRATEGIES ARE IMPLEMENTED
Description Score
There is a loss and theft register
All losses and theft are investigated
Total score
Percentage score %
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Element 300: Hospital receives a clean audit report from the Auditor General
RESP
ONS
IBLE PERSON
The Auditor General office conducts annual audits of state institutions.
REVIEWERThe audit report or certificate from the Auditor General should be requested to assess compliance to this element.
There is no checklist for this element
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Component 9: Governance
Sub-component 40: District Health Management Office (DHMO)
COMMITMENT FOR SUB-COMPONENT 40: Monitor the managerial and technical support provided to the hospital. The responsibility for this sub-component is with the Executive Management.
These Elements are only applicable to District Hospitals
ELE
ME
NTS
301 Hospital operational plan is included in the district health plan
302 Hospital participates in quarterly district performance reviews
303 The DHMO visits the hospital at least annually
304 Peer review of hospitals targeted to be Ideal are conducted
305 KPAs of the District manager must include oversight of the district hospital in achieving Ideal status
Vital Essential NB Important
Element 301: Hospital operational plan is included in the district health plan
RESP
ONS
IBLE PERSON The hospital should develop an annual operational plan in line with the strategy. Key performance areas in terms of human resources, health technology and finances should be incorporated within the District Health Plan.
REVIEWERRequest a copy of both the Hospital Operational Plan and District Health Plan to assess compliance.
There is no checklist for this element
Who is responsible for this sub-component?
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Element 302: Hospital participates in quarterly district performance reviews
RESP
ONS
IBLE PERSON The District hospital forms part of District Health services and the referral point for the clinics. Quarterly District Performance reviews should be conducted across all service delivery platforms in the district.
REVIEWERRequest copy of the minutes of the Quarterly Performance reviews for ecidence of the hospital participation.
There is no checklist for this element
Element 303: The DHMO visits the hospital at least annually
RESP
ONS
IBLE PERSON
The DHMO must have a planned schedule and set agenda for hospital annual visits. These visits form part of the governance function.
REVIEWER
The attendance register and DHMO site visit calendar should be reviewed as the source documents. Any reports produced by the DHMO should serve to triangulate the evidence..
There is no checklist for this element
Element 304: Peer review of hospitals targeted to be Ideal are conducted
RESP
ONS
IBLE PERSON
The District should assemble a team of peer reviewers from external facilities to conduct assessment of other facilities prior to the external assessment.
REVIEWER Evidence of the peer review inspections should be requested.
There is no checklist for this element
Element 305: KPAs of the District manager must include oversight of the district hospital in achieving Ideal status
RESP
ONS
IBLE PERSON
The District Manager is the Accounting Officer for all facilities within their jurisdiction. The KPA should include an oversight role for Ideal hospitals.
REVIEWERThe KPA of the district manager should be retrieved from the Human Resources to assess whether oversight of the hospital in achieving ideal status is included.
There is no checklist for this element
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7. References
1. The Presidency.National Planning Commission. National Development Plan 2030. Pretoria: 2012
2. National Department of Health. Norms and Standards Regulations Applicable to Different Categories
of Health Establishments In: Health NDo, (ed.). Regulation No 67. Pretoria: Government Gazette, 2018.
3. Ranchodi S, Adamsii C, Burgeriii R, et al. South Africa’s hospital sector: old divisions and new
developments. In: Padarath A and Barron P (eds) South African Health Review 2017. Durban: Health
System Trust, 2017.
4. Visser R, Bhana R and Monticelli F. National Health Care Facilities Baseline Audit 2012 2013. Durban:
Health System Trust.
5. National Department of Health. Ideal Clinic Definitions, Components and Checklists, Version 16. 2016.
Pretoria: National Department of Health.
6. National Department of Health. Regulation 185 of National Health Act 61 of 2003. Pretoria: Government
Gazette, 2012.
Disclaimer: This publication was produced for review by the United States Agency for International Development. It was prepared by Dr Shaidah Asmall, Senior Technical Advisor, who provided overall conceptual and technical editorial guidance and Dr Ozayr Mahomed of the Discipline of Public Health Medicine at the University of KwaZulu-Natal. The contents expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Funded by:
DEPARTMENT OF HEALTHTEL: 012 395 8000CIVITAS BUILDING
PRETORIAPRIVATE BAG X828, PRETORIA, 0001
www.doh.gov.za
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